Sustaining Quality Outcomes: Learning from the 2015 Healthgrades America s Best Hospitals Recipients

Transcription

1 Sustaining Quality Outcomes: Learning from the 2015 Healthgrades America s Best Hospitals Recipients Healthgrades th Street Denver, CO Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.

2 Discipline Makes the Difference for Sustained Performance The America s Best Hospitals designation highlights not only superior performance in risk-adjusted mortality and in-hospital complication rates; it focuses on the year-over-year accomplishment of superior outcomes. For over 15 years, Healthgrades has analyzed hospital performance and has identified hospitals that repeatedly differentiate themselves from their peers. Two groups emerge annually those with overall clinical excellence for at least six years and those who have done so for a minimum of three years. We recognize these groups as Healthgrades America s 50 Best Hospitals and America s 100 Best Hospitals as top performers passing the test of time. Focusing on Cardiac Care An analysis performed on the top-performing hospitals identifies a core group of six conditions where these hospitals significantly outperform their peers: Sepsis, Pneumonia, Heart Attack, Heart Failure, Respiratory Failure, and Stroke. These six cohorts accounted for 80.9% of the mortalities across all 19 mortality cohorts evaluated by Healthgrades. For this year s America s Best Hospitals analysis, in honor of American Heart Month, we sought to gain insight regarding the performance of America s Best Hospitals in Heart Attack and Heart Failure. We re pleased to share insights from two America s 100 Best Hospitals (Mills-Peninsula Medical Center of San Mateo, CA and Regions Hospital of St. Paul, MN) about what they have done to drive quality outcomes in Heart Attack and Heart Failure. These hospitals shared common themes in high clinical performance and specific best practices as they relate to these cohorts. By sharing their voices and practices, we hope to start a dialogue to help other organizations achieve and sustain superior performance. 2 Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.

3 Three Common Denominators Three common themes emerged in both Mills-Peninsula Medical Center and Regions Hospital, regardless of the cohort. 1. Vision: Both hospitals have created a culture and practice of going beyond current core measures and looking for protocols and procedures to address anticipated future core measures before they will be held accountable for them. 2. Evidence-based decision making: These hospitals are driven by protocols that they track, measure, analyze and adjust to improve outcomes for their patients. While they each have specific ways of achieving evidence-based decision making, the use of data is pervasive in their work. 3. Collaboration: Protocols are in place to drive communication among various departments in real time. Going beyond the culture of the hospital, these processes enforce collaboration and trust between care units. The Key Takeaway Discipline Is Required to Deliver on the Promise of Better Outcomes While there are common themes, ultimately the key takeaway is that discipline is required to sustain the actions that consistently lead to continued superior performance. These two America s Best Hospitals provide real, tangible examples of practices and protocols that drive the right behaviors resulting in better clinical performance. In their stories we find that focusing in these areas is not enough. These hospitals are tenaciously committed to providing better outcomes over an extended period of time delivering on the promise. Remaining dedicated, when so many other priorities could derail the process, is a significant strength. 3 Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.

4 Mills-Peninsula Medical Center: Heart Attack Mills-Peninsula Medical Center, an affiliate of Sutter Health, is a not-for-profit healthcare organization located in Burlingame, Calif. Mills-Peninsula is a 241-bed facility that provides compassionate, state-of-the-art care to patients. It is the recipient of Healthgrades America s 50 Best Hospitals Award two years in a row and a Healthgrades five-star recipient for treatment of heart attack for three consecutive years. We thank the following staff members of Mills-Peninsula Health Services for their insights: David Daniels, MD, Director of Catheterization Laboratory Allan Brody, MD, Medical Director of the Emergency Department and Chief of Staff Christopher White, MD, FACEP, Emergency Medicine Physician Collaboration & Trust Mills-Peninsula Medical Center has a long history of protocols designed to drive collaboration resulting in trusted relationships that reinforce cooperative behaviors. Overall, these communication protocols and mutual trust lead to decreased times in treating the patient. Everything starts in the field. The Emergency Department (ED) physicians have respect for their paramedics and trust them when they say they have a critical case in the field. The cardiology physicians trust that if the ED tells them the patient is critical, they should treat it as such. The ED can activate the Cath lab without the cardiologist evaluating the EKG. This empowers paramedics and nurses to obtain the EKGs and activate the lab based on the results they see. That enables faster treatment time and more lives saved. One call activation. One phone number activates the team and cuts down on the time it takes to get everyone organized. Physicians communicate via cell phone. They don t have to go through an answering service which may otherwise cause delay in treating a patient. It goes beyond the ED. Our five interventional cardiologists represent three different medical groups but you couldn t tell. We all work really well together. Our situation is very unique with respect to the collaboration that exists and I think that directly contributes to our outcomes. It s pervasive in the hospital. Not only with the physician staff, but the new CEO is a strong proponent in working things out collaboratively. Not putting up barriers is critical. It s a very unique environment in a hospital. Mills-Peninsula Medical Center Cast a Wide Net The protocols that allow for greater collaboration also help to cast a wide net in identifying patients that may present differently. Patients 30 years and older who have pain between their chin and belly button receive an EKG. This protocol ensures that patients, who present differently than having standard chest pain, are identified in time for the best treatment. Occasionally, a case occurs that does not have to go to the Cath lab. The ED and Cardiology Department accept a certain level of false activations in order to ensure that patients are identified and treated quickly. 4 Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.

5 At Mills-Peninsula Medical Center, there is about a 3% false-positive rate from the field, a percentage that the hospital is willing to take in order to safeguard the fastest identification and appropriate treatment for patients with AMI. The one call activation is the way to go. This puts executing the established protocol in the hands of the ER doctor. The constant communication between all parties and even direct line communication within 60 seconds of looking at the EKG is key. Then being able to point resources to where they matter most. All of this leads to better outcomes for patients. Mills-Peninsula Medical Center Community Involvement Community involvement education, public health announcements, coordination with community transport have made a difference in treating AMI patients sooner. Mills-Peninsula Medical Center helps coordinate the entire county as a single ST SEgment Elevation Myocardial Infarction (STEMI) system. The hospital participates in monthly meetings to look at the county data, in addition to their own, to work toward better outcomes for members of the community. The hospital works with the community to quickly coordinate transportation for cardiac patients for time-sensitive treatments. Should a transfer be needed, the county does not wait for a critical care transport team to get patients to Mills-Peninsula Medical Center. The risk of delay in waiting for critical care transport can be significant. The hospital makes it clear to the community that standard transport is appropriate to transport critical care patients to their ED for faster treatment. Community involvement in communicating about heart attack symptoms and treatment have been key in capturing patients early enough to make a difference. From a public health perspective, we have to tell consumers that if they have chest pain they have to come in to get treated. It s not something hospitals can control or measure but it s the thing that probably makes the most difference. I can be as fast as any cardiac interventionist on the planet, but if the patient sat at home for 15 hours before they came in, then the deed is done. It s the thing that can t be measured so people don t talk about it. Mills-Peninsula Medical Center Volume Is Key to Quality Physicians often agree that outcomes get better with practice. Dr. Archelle Georgiou, strategic advisor to Healthgrades, explains that the volume of procedures a doctor has performed is correlated with their results. Studies show that cardiac surgeons with the best outcomes should do at least 100 to 125 procedures a year to remain competent. There isn t a specific number for each type of procedure, but like any skill, practice gets closer to perfect. The physicians at Mills-Peninsula Medical Center share that perspective, recognizing in these procedures that volume has value in its relationship to quality outcomes. I truly believe that volume is the key to quality. You have to have a high enough volume. As volumes increase, people (physicians) gain more experience. They have fewer complications and are faster and more efficient. The other thing that happens is as volume grows, their judgment gets better as to what to do and what not to do. What we focus on is appropriate use, doing the right procedure for the right patient. Mills-Peninsula Medical Center 5 Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.

6 Vision Proactively solving problems before they emerge has been a key to success. From empowering the emergency department to activate the Cath lab rather than following a traditional chain of command, to working with the county to develop community transport protocols, which reduce time to treatment, Mills-Peninsula Medical Center proactively seeks ways of treating patients faster and with better outcomes. It goes beyond the culture of the hospital, however. It is a state of mind that drives the evidence used to make decisions, and the protocols developed to drive problem solving. We strongly believe that in the next five to ten years everything will be focusing on paying for quality. If we are going to be successful, we need to focus on what we re going to do in terms of quality. But we also have to be able to measure it. It s us taking a look at our data. We need to take a hard look at what we are doing and how we can do better. If we do that and continue to ratchet up our performance in outcomes, in five years when the payers say You know what? We aren t going to pay for this procedure unless you can show us that you meet this benchmark. Well we are already going to have met the benchmark. We re already going to have the data to show it to them before they ask for it. It s not just that it s going to set us up for success. It s also the right thing to do. That s why the shift is happening in healthcare. We want to be able to provide the best service with the best outcomes and the lowest length of stays. It s good for the patient. Mills-Peninsula Medical Center Regions Hospital: Heart Failure Established in 1872, Regions Hospital is part of HealthPartners the largest consumer-governed, non-profit healthcare organization in the nation, with a mission to improve health and well-being in partnership with members, patients, and the community. Regions Hospital and HealthPartners provides healthcare services in St. Paul and its surrounding communities, as well as for patients throughout Minnesota, western Wisconsin, and other Midwestern states. It is the recipient of Healthgrades America s 100 Best Hospitals Award for two years in a row, and a five-star recipient for the treatment of Heart Failure for four years in a row. We extend our thanks to following staff members of Regions Hospital for sharing their perspectives: Beth Heinz, VP of Operations and Chief Quality Officer Mike Cannon, Director of Nursing, Cardiovascular Services Tim Lindquist, Quality Reporting Advisor Terry Carter, Director, Cardiovascular Service Line Gretchen Leiterman, VP of Operations Katie Moriarty, MD, Department Head of Cardiology 6 Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.

7 Visionary Leadership Regions Hospital and HealthPartners have a commitment to both the current and future state of healthcare. The hospital is constantly pushing to achieve greater results for their patients by aligning vision with executable policies. The Regions Heart Failure clinic has been in place for 12 years while the Heart Failure Steering Committee has been in place for 10 years. The fact that the hospital was visionary enough to recognize this high-risk population 12 years ago is unique. Only recently has reimbursement started to be tied to outcomes in this cohort. Regions Hospital made the investment before financial incentives were established and has remained committed to this focus throughout the years. The majority of physicians at Regions Hospital are employees of HealthPartners rather than independent contractors. As employees, physicians are engaged in their jobs, aligned with quality outcomes incentives, and committed to the well-being of the hospital visionary in physician alignment. Regions Hospital has a committee focused on potential future core measures and how to develop protocols around those measures that will benefit patients. Getting ahead of potential requirements keeps them in front of the status quo. When you are in healthcare, you have to consider everything. You can t do just one or two things. We remember a time when it was hard to get a scale for our patients and it was hard to get them to weigh themselves. We started with the basics. Regions Hospital Data-Driven Decision Making Vision combined with data ensures an evidence-based approach to caring for patients. Regions Hospital has a long history of using electronic medical records (EMR). They have been using EMR technology for more than a decade, so using order sets is now routine. They now have the ability to move beyond compliance and are looking to develop new programs to benefit patients. Not only do they use the EMR, they have leveraged it to integrate outpatient care with inpatient care. The patient s medical problems and best practice treatments can now follow the patient and can be used in different settings. This ensures better outcomes for patients. The Heart Failure Steering Committee reviews all Medicare mortality cases. By holding themselves to this monthly commitment, the committee is able to mine cases for information that helps them make adjustments for better care. To be data driven hasn t been extremely easy because we are still working to optimize data. But it has pushed us to look at data in a different way. We are looking at where we ve had opportunities for improving patient care, and then we are making changes to our practice. Regions Hospital 7 Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.

8 Collaboration Collaborative protocols that drive communication between cardiology, hospital medicine, and emergency medicine ensure that Regions Hospital patients get to the right place for the right care. Low-risk cardiac protocols chest pain, congestive heart failure, and atrial fibrillation have all helped keep patients out of the hospital and get them into the clinic. These processes ensure these patients receive the best care for the lowest cost. Regions Hospital is part of an integrated healthcare organization that includes clinics, specialty care, hospitals, finance and payer. The culture aligns to focus the appropriate resources to improve care. Regions Hospital gets the right physician involved at the right time by leveraging the structured hand-off that the integrated organization affords them. Communicating areas for improvement is essential. The Heart Failure Steering Committee identifies goals, desired outcomes, gaps and areas for improvement. These results are then communicated to the physicians, nursing staff, and executives on a monthly basis. This clinical performance reflects the transparency and communication between the emergency and cardiovascular departments. Everyone is working toward a common goal. We re really fortunate to have the appropriate staffing and support to implement our programs. Regions Hospital 8 Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.

9 What Makes The Difference for Sustained Quality Outcomes? Mills-Peninsula Medical Center and Regions Hospital attribute their exceptional clinical performance to a collaborative approach to medicine, evidence-based decision making, and a culture of vision for the future of caring for patients. These elements are not only a part of their culture, but are built into the specific protocols they use on a daily basis. All hospitals have protocols and are committed to providing the best care possible. Mills-Peninsula Medical Center and Regions Hospital offer examples of a willingness to commit resources and time to execute those protocols to succeed. Every hospital has access to patient outcome data, but it s the commitment and rigor to use the data that matters. The two hospitals we feature here have demonstrated purposeful use and appropriate management of their data over long periods of time. This translates into better outcomes for their patient s year over year. America s Best Hospitals Methodology Healthgrades identifies America s Best Hospitals and stratifies performance into two categories: America s 50 Best Hospitals and America s 100 Best Hospitals. Identifying America s 50 Best Hospitals Healthgrades America s 50 Best Hospitals Award recognizes 50 hospitals as the top 1% in the nation for consistent clinical excellence based on an analysis of risk-adjusted mortality and complication rates for common procedures and conditions. Specifically, these hospitals have received a Healthgrades Distinguished Hospital Award for Clinical Excellence in consecutive years over an extended period of time. To identify America s 50 Best Hospitals, Healthgrades used a two-step process. 1. Identified those hospitals that received the Distinguished Hospital Award for Clinical Excellence for at least seven consecutive years. 2. If the number of hospitals identified above was less than 50, then the recipients for the last six consecutive years were identified and sorted by volume-weighted average z-score from the most recent Distinguished Hospital Award for Clinical Excellence analysis. (The volumeweighted average z-score is a statistical measure of hospital quality outcomes.) The top hospitals from this list were then added to the list from Step 1 above to create a list of America s 50 Best Hospitals for Identifying America s 100 Best Hospitals Healthgrades America s 100 Best Hospitals Award recognizes the top 100 hospitals that received the Distinguished Hospital Award for Clinical Excellence each year for at least the last three years. The list is made up of those hospitals that were identified as America s 50 Best Hospitals as described above with the addition of the next 50 top hospitals, identified by consecutive years of achieving the Distinguished Hospital Award for Clinical Excellence and volume-weighted average z-score. These hospitals are recognized as the top 2% in the nation for consistent clinical quality. About Healthgrades Healthgrades, headquartered in Denver, Colorado, is the leading online resource for comprehensive information about physicians and hospitals. Today, nearly one million people a day use the Healthgrades websites to search, compare and connect with hospitals and physicians based on the most important measures when selecting a healthcare provider: experience, hospital quality, and patient satisfaction. For more information about Healthgrades, visit or download the Healthgrades iphone app. 9 Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.

10 Healthgrades 2015 America s Best Hospitals List Healthgrades announces America s 100 Best Hospitals for These facilities are among the top 2% in the nation in providing superior outcomes as measured across at least 21 of 32 of the most common conditions and procedures for at least three consecutive years. Healthgrades also announces America s 50 Best Hospitals (highlighted in bold). These facilities are among the top 1% in the nation in providing superior outcomes as measured across at least 21 of 32 of the most common conditions and procedures for at least six consecutive years. State 2015 America s Best Hospital City Arizona Banner Estrella Medical Center Phoenix Chandler Regional Medical Center Chandler America s 50 Best Mayo Clinic Hospital Phoenix California Alta Bates Summit Medical Center - Summit Oakland Cedars - Sinai Medical Center Eden Medical Center Los Angeles Castro Valley Hoag Memorial Hospital Presbyterian Newport Beach Huntington Memorial Hospital Pasadena John Muir Medical Center - Walnut Creek Walnut Creek Kaiser Permanente Fremont Medical Center Kaiser Permanente Woodland Hills Medical Center Mercy San Juan Medical Center Northridge Hospital Medical Center Fremont Woodland Hills Carmichael Northridge Peninsula Medical Center Burlingame Including: Mills Health Center San Mateo PIH Health Hospital - Whittier Whittier Providence Saint John's Health Center Santa Monica Providence Tarzana Medical Center Tarzana Saddleback Memorial Medical Center Laguna Hills Scripps Green Hospital St. John's Regional Medical Center Sutter General Hospital La Jolla Oxnard Sacramento Including: Sutter Memorial Hospital Sacramento Sutter Roseville Medical Center Roseville Colorado Centura Health - Penrose Saint Francis Health Services Colorado Springs Including: St. Francis Medical Center Colorado Springs Lutheran Medical Center Wheat Ridge North Colorado Medical Center Greeley Saint Joseph Hospital Denver Continued 10 Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.

11 Healthgrades 2015 America s Best Hospitals List (continued) State 2015 America s Best Hospital City America s 50 Best Florida Delray Medical Center Delray Beach Fawcett Memorial Hospital Port Charlotte Lee Memorial Hospital Fort Myers Including: HealthPark Medical Center Fort Myers Martin Medical Center Stuart Including: Martin Hospital South Stuart Munroe Regional Medical Center Ocala Georgia Northeast Georgia Medical Center Gainesville Piedmont Fayette Hospital Fayetteville Idaho St. Luke s Regional Medical Center Boise Illinois Advocate Christ Hospital and Medical Center Oak Lawn Advocate Good Samaritan Hospital Downers Grove Alexian Brothers Medical Center Elk Grove Village Carle Foundation Hospital Urbana Palos Community Hospital Palos Heights Presence Resurrection Medical Center Chicago Presence Saint Joseph Medical Center Joliet Saint Alexius Medical Center Hoffman Estates Indiana Franciscan St. Francis Health- Indianapolis Indianapolis Indiana University Health Arnett Hospital Lafayette Indiana University Health Methodist Hospital Indianapolis Including: Indiana University Health University Hospital Indianapolis Iowa Mercy Medical Center - Cedar Rapids Cedar Rapids Saint Lukes Hospital Cedar Rapids Kansas The University of Kansas Hospital Kansas City Louisiana Ochsner Medical Center New Orleans Including: Ochsner Medical Center- West Bank Campus Gretna Ochsner Health Center- Elmwood New Orleans Maryland Greater Baltimore Medical Center Towson Medstar Franklin Square Medical Center Baltimore Medstar Good Samaritan Hospital Baltimore Medstar Harbor Hospital Baltimore University of Maryland St. Joseph Medical Center Towson Massachusetts Baystate Medical Center Springfield Holy Family Hospital Methuen Continued 11 Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.

12 Healthgrades 2015 America s Best Hospitals List (continued) State 2015 America s Best Hospital City 12 America s 50 Best Michigan Beaumont Health System - Beaumont - Troy Campus Troy Henry Ford Wyandotte Hospital Wyandotte Holland Hospital Holland McLaren Macomb Mount Clemens Spectrum Health Medical Center - Butterworth Hospital Grand Rapids Including: Spectrum Health - Blodgett Hospital Grand Rapids St. John Providence Health System - Providence Hospital - Southfield Campus Southfield Minnesota AllinaHealth - Unity Hospital Fridley Mayo Clinic Hospital - Saint Mary's Campus Rochester North Memorial Medical Center Robbinsdale Regions Hospital Saint Paul Missouri Barnes - Jewish Saint Peters Hospital Saint Peters Heartland Regional Medical Center Saint Joseph St. Luke's Hospital Chesterfield Nebraska Bryan Health Medical Center - East Lincoln Including: Bryan Medical Center West Lincoln New Jersey Hackensack UMC Hackensack Morristown Medical Center Morristown New York NewYork-Presbyterian/Weill Cornell Medical Center New York Including: NewYork-Presbyterian/Columbia University Medical Center New York NewYork-Presbyterian/The Allen Hospital New York North Shore University Hospital Manhasset Including: North Shore University Hospital Syosset Syosset Saint Peter's Hospital Vassar Brothers Medical Center Albany Poughkeepsie North Carolina Mission Health Asheville Ohio Bethesda North Hospital Cincinnati Christ Hospital Cincinnati Marymount Hospital Garfield Heights ProMedica Toledo Hospital South Pointe Hospital Toledo Warrensville Heights Oregon Asante Rogue Regional Medical Center Medford Pennsylvania Jefferson University Hospitals - City Center Philadelphia Including: Methodist Hospital Philadelphia Lancaster General Hospital Lancaster Lehigh Valley Hospital - Cedar Crest Allentown Penn Presbyterian Medical Center Philadelphia Continued Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.

13 Healthgrades 2015 America s Best Hospitals List (continued) State 2015 America s Best Hospital City America s 50 Best South Carolina AnMed Health Medical Center Anderson Texas Houston Methodist Hospital Houston Including: Diagnostic Center Hospital Houston Scott and White Memorial Hospital St. David's Medical Center Temple Austin Including: Heart Hospital of Austin Austin St. David's Georgetown Hospital Georgetown Virginia Augusta Health Fishersville Bon Secours Memorial Regional Medical Center Mechanicsville Henrico Doctors' Hospital Richmond Including: Parham Doctors' Hospital Richmond Retreat Doctors' Hospital Richmond Washington PeaceHealth St. Joseph Medical Center Bellingham Virginia Mason Medical Center Seattle Wisconsin Aspirus Wausau Hospital Wausau Aurora Saint Luke s Medical Center Milwaukee Including: Saint Luke s Medical Center Cudahy Aurora Sinai Medical Center Milwaukee Gundersen Lutheran Medical Center La Crosse Wheaton Franciscan - Saint Joseph Milwaukee Including: Wheaton Franciscan - Elmbrook Memorial Brookfield The Wisconsin Heart Hospital Wauwatosa 13 Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.

14 Healthgrades MedPAR-based Awards 2015 Methodology Specialty Excellence Award & America s Best Hospitals for Specialty Care Distinguished Hospital Award for Clinical Excellence America s 50 Best Hospitals & America s 100 Best Hospitals Performance Measurement: Ratings and Awards... 2 Using Ratings to Communicate Performance... 2 Using Awards to Communicate Performance... 3 Specialty Excellence Awards & America s Best for Specialty Care... 4 Specialty Excellence Awards... 4 Specialty Excellence Award Determination... 4 America s 100 Best Hospitals for Specialty Care... 4 America s 50 Best Hospitals for Specialty Care... 4 Specialty Award Categories and Requirements... 5 Cardiac Care... 5 Cardiac Surgery... 5 Coronary Intervention... 5 Critical Care... 6 Gastrointestinal Care... 6 General Surgery... 6 Joint Replacement... 7 Neurosciences... 7 Neurosurgery... 7 Orthopedic Surgery... 7 Prostate Surgery... 8 Pulmonary Care... 8 Spine Surgery... 8 Stroke Care... 8 Vascular Surgery... 8 Distinguished Hospital Award for Clinical Excellence Methodology... 9 Procedures and Conditions Evaluated for DHA-CE Calculation... 9 Eligibility... 9 Clinical Excellence Award Determination America s Best Hospitals Methodology 11 Identifying America s 50 Best Hospitals Identifying America s 100 Best Hospitals Confidential Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc.

15 Healthgrades Award Methodology: Specialty Excellence Awards & America s Best for Specialty Care Performance Measurement: Ratings and Awards To help consumers evaluate and compare hospital performance specific to specialty service lines and specialty focus areas. Healthgrades communicates performance in two ways through ratings and awards. To measure performance, Healthgrades used Medicare inpatient data from the Medicare Provider Analysis and Review (MedPAR) database purchased from the Centers for Medicare and Medicaid Services (CMS) for years 2011 through Patient outcomes data for 32 conditions or procedures were analyzed (see list below) for virtually every hospital in the country. Mortality-Based Procedures & Conditions Bowel Obstruction Chronic Obstructive Pulmonary Disease (COPD) Colorectal Surgeries Coronary Artery Bypass Graft (CABG) Surgery Coronary Interventional Procedures Diabetic Emergencies Esophageal/Stomach Surgeries Gastrointestinal Bleed Heart Attack Heart Failure Neurosurgery Pancreatitis Pneumonia Pulmonary Embolism Respiratory Failure Sepsis Small Intestine Surgeries Stroke Valve Surgery In-Hospital Complications-Based Procedures & Conditions Abdominal Aortic Aneurysm Repair Back and Neck Surgeries (Without Spinal Fusion) Carotid Surgery Defibrillator Procedures Gallbladder Surgery Hip Fracture Treatment Hip Replacement Using Ratings to Communicate Performance Pacemaker Procedures Peripheral Vascular Bypass Prostate Removal Surgery Spinal Fusion Total Knee Replacement Transurethral Prostate Resection Surgery The first and most fundamental way that Healthgrades communicates performance is through star ratings. Star ratings are an evaluation of the hospital s actual performance as compared to the predicted performance for that hospital based on a specific risk-adjustment model applied to that hospital. For more details, see the Healthgrades Mortality and Complications Outcomes 2015 Methodology. The purpose of risk adjustment is to obtain fair statistical comparisons of mortality and complication rates between hospitals while accounting for differences in underlying risk factors observed in the data among disparate populations or groups. Significant differences in clinical and demographic risk factors are found among patients treated in different hospitals. Therefore, it is necessary to make accurate and valid comparisons of clinical outcomes with a methodology using risk-adjustment techniques. Risk factors may include age, gender, specific procedure performed, and co-morbid conditions, such as hypertension or diabetes. Confidential Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc. 2

16 Healthgrades Award Methodology: Specialty Excellence Awards & America s Best for Specialty Care Developing the Healthgrades hospital star performance categories involves four steps: 1. The hospital predicted value (predicted number of deaths or complications at each hospital) is calculated by summing the individual patient record predicted values determined from logistic regression models discussed above. 2. The hospital predicted value is compared with the actual or observed value (e.g., actual number of deaths or complications at each hospital). 3. A test is conducted to determine whether the difference between the predicted and actual values was statistically significant. This test is performed to make sure that differences were very unlikely to be caused by chance alone. A z-score is used to establish a 90% confidence interval. 4. Hospital performance categories are determined based upon the outcome of the test for statistical significance. For each condition or procedure, hospital performance is evaluated and stratified into three categories: Better Than Expected Actual performance was better than predicted and the difference was statistically significant at alpha = 0.1. As Expected Actual performance was not statistically significantly different from what was predicted at alpha = 0.1. Worse Than Expected Actual performance was worse than predicted and the difference was statistically significant at alpha = 0.1. Healthgrades uses z-scores (individual or aggregate) to determine performance. A z-score is a standardized statistical test which calculates the difference between the actual and predicted complication and mortality rates, taking into account patient variability and volume. A higher z-score means better performance. A complete description of the methodology including all exclusions, inclusions, risk factors, multivariate logistic regression model and other relevant information is available in the Healthgrades Mortality and Complications Outcomes 2015 Methodology. Using Awards to Communicate Performance The second way Healthgrades communicates information on performance is by awards. Awards determine and communicate a hospital s superior performance when compared to other eligible hospitals. Each award has eligibility requirements specific to the nature and intent of the award. All awards require that a hospital receive a rating in the cohort(s) included in the determination of the award. Awards may reference a singular cohort or require the combination of a grouping of cohorts. Specific information on the cohorts included is outlined in the Specialty Award Categories and Requirements section. Confidential Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc. 3

17 Healthgrades Award Methodology: Specialty Excellence Awards & America s Best for Specialty Care Specialty Excellence Awards & America s Best for Specialty Care Three Healthgrades awards recognized hospitals for superior performance in specialty care: Healthgrades Specialty Excellence Awards America s 100 Best Hospitals for Specialty Care America s 50 Best Hospitals for Specialty Care Specialty Excellence Awards Healthgrades Specialty Excellence Awards recognize hospitals with superior performance in specific specialty lines and specialty focus areas. Healthgrades current Specialty Excellence Awards include: Cardiac Care Excellence Award Cardiac Surgery Excellence Award Coronary Intervention Excellence Award Critical Care Excellence Award Gastrointestinal Care Excellence Award General Surgery Excellence Award Joint Replacement Excellence Award Neurosciences Excellence Award Neurosurgery Excellence Award Orthopedic Surgery Excellence Award Prostate Surgery Excellence Award Pulmonary Care Excellence Award Spine Surgery Excellence Award Stroke Care Excellence Award Vascular Surgery Excellence Award Specialty Excellence Award Determination For each hospital, Healthgrades assigns an overall score for each specialty area based on hospital performance as determined by a single z-score or average of volume-weighted z-scores when more than one condition or procedure is included in the award. (See Specialty Award Categories and Requirements for a list for each award). The top 5% or 10% of hospitals within each specialty area are recognized as Healthgrades Specialty Excellence Award recipients, as measured by lowest risk-adjusted mortality and complication z- scores. America s 100 Best Hospitals for Specialty Care From the lists of Specialty Excellence Award recipients, Healthgrades further identified the top 100 hospitals for each of 11 specialty areas based on overall z-scores. For there to be 100 Best Hospitals for specialty care, 100 hospitals or more must perform in the top 5% or 10% in the nation. Cardiac Care Coronary Intervention Critical Care Gastrointestinal Care General Surgery Joint Replacement Orthopedic Surgery Prostate Surgery Pulmonary Care Spine Surgery Stroke Care America s 50 Best Hospitals for Specialty Care From the lists of Specialty Excellence Award recipients, Healthgrades identified the top 50 hospitals for two specialty areas based on overall z-scores. In these two specialty categories, only 50 hospitals in the nation performed among the top 5% or 10% in the nation. Cardiac Surgery Vascular Surgery Confidential Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc. 4

18 Healthgrades Award Methodology: Specialty Excellence Awards & America s Best for Specialty Care Specialty Award Categories and Requirements The following sections provide a list of conditions, procedures and analyses that are included for each Specialty Excellence Award. Cardiac Care The Cardiac Care specialty award is based on: Coronary Artery Bypass Graft (CABG) Surgery Coronary Interventional Procedures (PCI) Heart Attack Heart Failure Valve Surgery To be considered for an award in this specialty area, a hospital has to be evaluated in four of the five procedures listed above based on MedPAR data. The four must include coronary interventional procedures, heart attack, heart failure, and either coronary artery bypass graft (CABG) surgery or valve surgery. The z-scores for in-hospital mortality and in-hospital + 30 day mortality are used in calculating the area scores. The in-hospital + 30 day mortality outcome receives 60% of the weight in the calculations and in-hospital mortality receives 40% of the weight. A volume-weighted average z-score is calculated for the combination of cardiac surgery (CABG surgery and Valve Surgery). A volume-weighted average z-score is also calculated for heart attack and heart failure. A z-score is also calculated for coronary interventional procedures. The Cardiac Care award is based evenly on average of the combined cardiac surgery (CABG surgery and Valve Surgery) z-score, the combined heart attack and heart failure z-score, and the score for coronary interventional procedures. Cardiac Surgery The Cardiac Surgery specialty award is based on: Coronary Artery Bypass Graft (CABG) Surgery Valve Surgery To be considered for an award in this specialty area, a hospital has to be evaluated in both of the above procedures based on MedPAR data. The Cardiac Surgery award is determined by the volume-weighted average of coronary artery bypass graft (CABG) surgery and valve surgery z-scores. The z-scores for inhospital mortality and in-hospital + 30 day mortality are used in these calculations. The in-hospital + 30 day mortality outcome receives 60% of the weight in the calculations and in-hospital mortality receives 40% of the weight. Coronary Intervention The Coronary Intervention specialty award is based on one cohort: coronary interventional procedures (angioplasty/stent).the Coronary Intervention award is based on the average of in-hospital mortality and in-hospital + 30 day mortality z-scores based on MedPAR data. The in-hospital + 30 day mortality outcome receives 60% of the weight in this calculation and in-hospital mortality receives 40% of the weight. Confidential Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc. 5

19 Healthgrades Award Methodology: Specialty Excellence Awards & America s Best for Specialty Care Critical Care The Critical Care specialty award is based on: Diabetic Emergencies Pulmonary Embolism Respiratory Failure Sepsis To be considered for an award in this specialty area, a hospital has to be evaluated in at least three out of four of the conditions listed above, based on MedPAR data. Healthgrades calculates the average z- scores for sepsis, pulmonary embolism, diabetic emergencies, and respiratory failure using in-hospital mortality and in-hospital + 30 day mortality. The in-hospital + 30 day mortality receives 60% of the weight in this calculation and in-hospital mortality receives 40% of the weight. The Critical Care award is based on a volume-weighted average of these average z-scores. Gastrointestinal Care The Gastrointestinal Care specialty award is based on: Bowel Obstruction Colorectal Surgeries Esophageal/Stomach Surgeries Gallbladder Removal Surgery Gastrointestinal Bleed Pancreatitis Small Intestine Surgeries To be considered for an award in this specialty area, a hospital has to be evaluated in at least five out of seven of the conditions or procedure cohorts listed above, based on MedPAR data. Healthgrades calculates the average z-scores for each cohort using in-hospital mortality and in-hospital + 30 day mortality. The in-hospital + 30 day mortality receives 60% of the weight in this calculation and inhospital mortality receives 40% of the weight. The Gastrointestinal Care award is based on a volumeweighted average of these average z-scores. General Surgery The General Surgery specialty award is based on: Bowel Obstruction Colorectal Surgeries Esophageal/Stomach Surgeries Gallbladder Removal Surgery Small Intestine Surgeries To be considered for an award in this specialty area, a hospital has to be evaluated in at least four out of five of the conditions or procedure cohorts listed above, based on MedPAR data. Healthgrades calculates the average z-scores for each cohort using in-hospital mortality and in-hospital + 30 day mortality. The in-hospital + 30 day mortality receives 60% of the weight in this calculation and inhospital mortality receives 40% of the weight. The General Surgery award is based on a volumeweighted average of these average z-scores. Confidential Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc. 6

20 Healthgrades Award Methodology: Specialty Excellence Awards & America s Best for Specialty Care Joint Replacement The Joint Replacement specialty award is based on: Hip Replacement Total Knee Replacement To be considered for an award in this specialty area, a hospital had to be evaluated and categorized into one of three performance categories for both total knee replacement and hip replacement. We evaluate both procedures based on in-hospital complications. The Joint Replacement award is based on a volume-weighted average of the z-scores for these procedures. Neurosciences The Neurosciences specialty award is based on: Neurosurgery Stroke To be considered for an award in this specialty area, a hospital has to be evaluated for both of these conditions and procedures based on MedPAR data. We first calculate the average z-scores for each condition or procedure using in-hospital mortality and in-hospital + 30 day mortality. The in-hospital + 30 day mortality receives 60% of the weight in this calculation and in-hospital mortality receives 40% of the weight. The Neurosciences award is the volume-weighted average of these two z-scores. Neurosurgery The Neurosurgery specialty award is based on one group of procedures: neurosurgery. The neurosurgery score is calculated using the average of in-hospital mortality and in-hospital + 30 day mortality z-scores based on MedPAR data. The in-hospital + 30 day mortality receives 60% of the weight in this calculation and in-hospital mortality receives 40% of the weight. Orthopedic Surgery The Orthopedic Surgery specialty award is based on: Back and Neck Surgeries (Without Spinal Fusion) Hip Fracture Treatment Hip Replacement Spinal Fusion Total Knee Replacement To be considered for an award in this specialty area, a hospital has to be evaluated in four of the five procedures listed above based on MedPAR data. Those four must include total knee replacement, hip replacement, hip fracture treatment, and either spinal fusion and/or back and neck surgeries. These procedures are evaluated based on complication rates. A volume-weighted average z-score is calculated for the combination of the joint replacement procedures (both are required) and for the combination of spinal fusion and back and neck surgeries (only one is required). A z-score is also calculated for hip fracture treatment. The Orthopedic Surgery award is based on the evenly weighted average of the joint replacement z-score, the combined back and neck z-score, and the hip fracture z- score. Confidential Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc. 7

21 Healthgrades Award Methodology: Specialty Excellence Awards & America s Best for Specialty Care Prostate Surgery The Prostate Surgery specialty award is based on: Prostate Removal Surgery Transurethral Prostate Resection Surgery To be considered for an award in this specialty area, a hospital has to be evaluated for either one or both conditions based on MedPAR data. We evaluate both procedures based on in-hospital complications. The Prostate Surgery award is based on the volume-weighted average of the z-scores for these procedures or the direct z-score if only one type of procedure is performed. Pulmonary Care The Pulmonary Care specialty award is based on: Chronic Obstructive Pulmonary Disease (COPD) Pneumonia To be considered for an award in this specialty area, a hospital has to be evaluated in both conditions based on MedPAR data. We first calculate the average z-scores for these conditions using in-hospital mortality and in-hospital + 30 day mortality. The in-hospital + 30 day mortality receives 60% of the weight in this calculation and in-hospital mortality receives 40% of the weight. The Pulmonary Care award is based on a volume-weighted average of these average z-scores. Spine Surgery The Spine Surgery specialty award is based on: Back and Neck Surgeries (Without Spinal Fusion) Spinal Fusion To be considered for an award in this specialty area, a hospital has to be evaluated in both procedures based on MedPAR data. We evaluate both procedures based on in-hospital complications. The Spine Surgery award is the volume-weighted average of these z-scores for these procedures. Stroke Care The Stroke Care specialty award is based on one condition: stroke. To be evaluated, a hospital has to have a transfer-out rate of less than 10% for the three years of data used. The Stroke Care award is based on the average z-scores for in-hospital mortality and in-hospital + 30 day mortality. The inhospital + 30 day mortality receives 60% of the weight in this calculation and in-hospital mortality receives 40% of the weight. Vascular Surgery The Vascular Surgery specialty award is based on: Abdominal Aortic Aneurysm Repair Carotid Surgery Peripheral Vascular Bypass To be considered for an award in this specialty area, a hospital s performance has to be evaluated for all three procedures based on MedPAR data. We evaluate all three procedures based on in-hospital complications. The Vascular Surgery award is based on the volume-weighted average of the z-scores for these three procedures. Confidential Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc. 8

22 Healthgrades Award Methodology: Distinguished Hospital Award for Clinical Excellence Distinguished Hospital Award for Clinical Excellence Methodology The Distinguished Hospital Award for Clinical Excellence recognizes hospitals for superior performance in providing care for conditions and procedures across multiple specialty lines and areas. The Distinguished Hospital Award for Clinical Excellence recognizes the top 5% of hospitals in the country for clinical excellence. While many hospitals have specific areas of expertise and high-quality outcomes in certain areas, these hospitals exhibit comprehensive high-quality care across clinical areas. To help consumers evaluate and compare hospital performance relative to this award, Healthgrades uses a two-step methodology: 1. Evaluate hospital performance for 32 procedures and conditions using Healthgrades Mortality and Complication Outcomes Methodology (see list below). 2. Identify the hospitals with superior performance overall for up to 32 of these conditions and procedures using this Distinguished Hospital Award for Clinical Excellence Methodology. Procedures and Conditions Evaluated for DHA-CE Calculation The following 32 procedures and conditions are used in this methodology. Mortality-Based Procedures & Conditions Bowel Obstruction Chronic Obstructive Pulmonary Disease (COPD) Colorectal Surgeries Coronary Artery Bypass Graft (CABG) Surgery Coronary Interventional Procedures Diabetic Emergencies Esophageal/Stomach Surgeries Gastrointestinal Bleed Heart Attack Heart Failure Neurosurgery Pancreatitis Pneumonia Pulmonary Embolism Respiratory Failure Sepsis Small Intestine Surgeries Stroke Valve Surgery In-Hospital Complication-Based Procedures & Conditions Abdominal Aortic Aneurysm Repair Back and Neck Surgeries (Without Spinal Fusion) Carotid Surgery Defibrillator Procedures Gallbladder Removal Surgery Hip Fracture Treatment Hip Replacement Pacemaker Procedures Peripheral Vascular Bypass Prostate Removal Surgery Spinal Fusion Total Knee Replacement Transurethral Prostate Resection Surgery Eligibility To be considered for the Healthgrades Distinguished Hospital Award for Clinical Excellence, a hospital has to have evaluations in at least 21 of the 32 Healthgrades procedures and conditions using Medicare inpatient data from the Medicare Provider Analysis and Review (MedPAR) database purchased from the Centers for Medicare and Medicaid Services (CMS). Confidential Copyright 2015 Healthgrades Operating Company, Inc. All Rights Reserved. May not be reproduced or redistributed without the express permission of Healthgrades Operating Company, Inc. 9