The Centers for Medicare and Medicaid have required hospitals to start reporting on quality criteria for reimbursement consideration as early as 2012, based on 2010 health care reforms. Major changes that clinicians and hospitals must conform to include:
Value-based Purchasing-This provides greater reimbursement with an emphasis on better clinical outcomes, starting in 2013.
Risk-Adjusted Reimbursement-This accounts for higher risk patients with multiple conditions and gives the doctor a higher fee to manage their care than previously, effective in 2014.
Reduced Payments for Hospitals with Excessive Re-admission Rates-This is a penalty for poorer performance and is effective in 2013 for hospitals who do not perform within certain guidelines for specific diagnoses.
This article reviews a report commissioned by The Commonwealth Fund to analyze some of the things the top performing hospitals, who submitted to quality surveys by the independent quality watch dog nonprofit, Leapfrog Group, are doing to improve clinical care and efficiency at their facilities.
Case Study Criteria
This information was drawn from case study analysis of 4 hospitals out of the top 13 hospitals in Leapfrog's Highest Value Hospital criteria using their 2008 survey data. Standards reviewed included short lengths of stay and low readmission rates for the following cardiac procedures; CABG, PCI, and AMI, in addition to pneunomia. The case study review was conducted by Jennifer Edwards, Sharon Silow-Carroll, and Aimee Lashbrook in a report entitled, Achieving Efficiency: Lessons from Four Top Performing Hospitals and was published as a Synthesis Report for the Commonwealth Fund in July 2011.Hospitals included in the report are Fairview Southdale Hospital in Edina, Minnesota,Park-Nicollet Methodist Hospital in Minneapolis, Minnesota, North Mississippi Medical center in Tupelo, Mississippi, and Providence St. Vincent's Medical center in Portland, Oregon. These hospitals scored high in at least three of the four criteria and were recognized as high value hospitals. The Commonwealth Fund commissioned the study in order to assess what hospitals were doing to create high quality outcomes with low resource investments, in other words, producing good results for less money. Here are the top factors influencing high patient quality outcomes at hospitals, listed in order of precedence:
Full-time Quality Assessment Departments
All four hospitals have full-time quality development, measurement, and compliance departments, but the difference between the best scoring facilities and the medium hospitals was how they trained their staff to solve quality problems as a part of their job. This includes clinical and nonclinical staff that assess performance improvement processes. At Fairview Southdale, every department director is required to sponsor at least two initiatives to improve clinical quality and produce a minimum of $60,000 in savings yearly.
Matrix Management Models Enhance Fluid Organizational Changes
In the top hospitals, executives with more fluid organizational roles rather than hierarchical, were able to make systemic adjustments more readily. Matrix operational models support management changes based on organizational links impacting outcomes rather than chain-of-command methods.
Increased Use of Hospitalists as Patient Care Coordinators
All four of these hospitals used hospitalists to coordinate inpatient care rather than "on-call" physicians. These full-time clinicians make patient assessments and provide greater continuity of patient care, making it easier to measure and track patient health. It is easier to implement standards of practice changes with full-time employees than independent contractors. Notably, the Accountable Care Organization criteria looks at reduced hospital re-admissions when rewarding hospitals with higher payments.
Engaging Staff: Quality Improvement is the Responsibility of Everyone
North Mississippi Medical Center, a recipient of the Malcolm Baldridge Award for Quality, solicits all its employees for ideas on process improvement and in 2008, 37% of those were implemented. This process is reinforced through recognition and incentives. Staff empowerment is also one of the measures for the Baldridge Award. St, Vincent's Hospital in Portland, Oregon created a new model to increase staff engagement, called self-governance or one-team-many-hands approach, which gives all staffers representation in hospital decision making.
Information Systems Supporting Patient Care
St. Vincent's and Fairview Southdale are part of integrated systems where patients can request medications on-line, facilitate non emergency health assessments, and schedule appointments. It is much harder for nonintegrated health systems to offer these tools, but here are some of the creative things these facilities have done with technology to improve patient care:
1. An electronic bed board for optimizing facility space and accommodating patients.
2. Patient discharge systems for streamlining patient processes when leaving the facility.
3. An internal alert process when a unit is close to capacity so other departments can handle the back fill.
4. Fairview Southdale uses wireless technology to allow ambulances to send electrocardiograms to the hospital when a patient is enroute, which reduces patient care time by twenty minutes.
Standardization and Simplification
All four hospitals had processes to eliminate unnecessary redundancies, reduce patient slow downs, and stop errors. Something as simple as a defined protocol for assigning a bed for a patient eliminated slowdowns. And in health care, minimizing delays means patients obtain care quicker and financially the facility is able to optimize its resources for all patients. St. Vincent's uses a staggered staffing system to avoid shift change down time.
Centers for Medicare and Medicaid Demonstration Projects
Here is a brief list of health care demonstration projects through CMS:
Global Capitation Payments-This is a project which is in five states and attempts to address the hospital safety net, which is the extent hospitals serve the poor and uninsured, and it runs from 2010 to 2012.
Medicare Shared Savings-
Medicaid Children's Health Insurance Shared Savings Program-Like the adult shared savings program.
Bundled Medicaid Demonstration Projects-This reviews episodes of care in a hospital and other settings, is deployed in eight states, and runs from 2012 to 2016.
Bundled Medicare Payments-This is a method of enhancing primary or Medical Home provisions to increase clinician reimbursement for patient care.
In closing, all of the selected hospitals were part of health systems, where benchmarking and resourcing services are readily available, which could be problematic for community hospitals lacking these resources. Still, these four stellar hospitals provide creative solutions for managing patient care on a budget, in urban and suburban settings.
It was excruciating to sequester myself to write this article when it is the peak of the Pacific Northwest nirvana weather, so I thank those of you who are going to read it tomorrow morning when it posts. My service to you is reducing the 25 page report down to less than 2 pages. This is the healthpolicymaven signing off in 78 degree air with 56% humidity.