Indiana Healthcare Quality

2013-02-02T12:28:00.000-05:00

So my plan was to just let this blog die since the purpose that this was initially designed to serve is no longer relevant. However, I've noticed a recent surge in traffic as the general public looks for hospital specific HCAHPS performance information in Indiana.

I have no idea how long I will continue this, but I'll have the most recent HCAHPS and other CMS posted quality information from Indiana posted in a few days/week.

Four of Seven Organizations Honored by The Partnership for Excellence are from Indiana!

2012-05-31T19:29:00.000-04:00

On May 8, The Partnership for Excellence (TPE) announced its 2012 Award Winners. Of the 7 award recipients, 4 are from Indiana!

The Indiana organizations are:

Citizens Energy Group (Indianapolis) - Platinum, Governer's Award for Excellence.
Good Samaritan Hospital (Vincennes) - Silver, Commitment to Excellence.
Westfield Washington Schools (Westfield) - Silver, Commitment to Excellence.
Working Well, (Michigan City) - Bronze, Pledge to Excellence.

2012 is the first year that Indiana has had a local or regional Baldrige-based performance excellence award program. The Fall of this year is also the first time that Baldrige Examiner training will be offered in Indiana (VHA Central office, Indianapolis). Note that this training is to specifically serve TPE, not the national Baldrige program.

To learn more about TPE: http://www.thepartnershipforexcellence.org/
To learn more about Baldrige Examiner training offered by the TPE: http://www.thepartnershipforexcellence.org/doc/2012_Call_for_Examiners_03-13-12.doc

The full press release announcing the 2012 TPE Award Recepitants is here: http://www.thepartnershipforexcellence.org/html/press_releases/press_release_05-08-12_Award_Recipients_2012.htm

Joint Commission Publishes new Monograph about CLABSIs

2012-05-31T19:13:00.000-04:00

On May 16th, the Joint Commission released a new Monograph reviewing the most recent evidence and thoughts surrounding Central Line-Associated Bloodstream Infections.

The free monograph can be downloaded here: http://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf

Below is an excerpt from the press release announcing the free monograph (emphasis added in red):

The Joint Commission, in collaboration with Joint Commission Resources (JCR) and Joint Commission International (JCI), developed a new monograph containing the most current information, evidence-based guidance and resources to help health care organizations reduce the current risks and resulting harm associated with CLABSI. JCR and JCI are not-for-profit affiliates of The Joint Commission. The monograph was produced in partnership with infection prevention leaders from the Society for Hospital Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), the National Institutes of Health (NIH), the Infectious Diseases Society of America (IDSA), the Association for Vascular Access (AVA), and the International Nosocomial Infection Control Consortium (INICC). In addition, several other domestic and international infection prevention leaders from countries such as Argentina, Australia, Egypt, Switzerland, Thailand and Saudi Arabia have lent their expertise to the monograph.

“Recent patient safety initiatives have demonstrated how preventable CLABSIs can be when evidence-based guidelines are consistently put into practice at the bedside,” says Jerod M. Loeb, Ph.D., executive vice president, Division of Healthcare Quality Evaluation, The Joint Commission. “Our hope is that these resources will empower health care providers to implement practices that have been shown to not only improve patient safety, but also reduce costs.”

The project is supported by a research grant from Baxter Healthcare Corporation and focuses on the identification and broad dissemination of preferred practices and technological solutions to prevent CLABSI.

Large Range in Patient Experience of Pain in Indiana Hospitals

2012-04-29T23:48:00.000-04:00

In the most recent CMS release (April 2012) of HCAHPS performance data, Indiana hospitals show a large range in the patient's experience of pain.

From April 1, 2010, to March 31, 2011, 83% of patients from Kentuckiana Medical Center (Clarksville, IN) who responded to the HCAHPS survey responded that their pain was "Always" well controlled. This compares to only 56% of responding patients from Saint Catherine Regional Hospital (Charlestown ,IN). The Indiana State average was 71% for this time period.

Although some caution needs to be exercised when comparing hospitals (due to services offered), there appears to be significant opportunity for Indiana hospitals to improve the patient experience. Given that Kentuckiana Medical Center, Physicians' Medical Center, Margaret Mary Community, Indiana Orthopedic, and St.Vincent Heart Center are in the top 5% nationally in this specific HCAHPS question, Indiana hospitals may be able to draw some best practices from within our own state.

Patients responding Pain was "Always" well controlled.
Hospital Name	City	% Always
KENTUCKIANA MEDICAL CENTER LLC	CLARKSVILLE	83
PHYSICIANS' MEDICAL CENTER LLC	NEW ALBANY	81
MARGARET MARY COMMUNITY HOSPITAL INC	BATESVILLE	79
INDIANA ORTHOPAEDIC HOSPITAL LLC	INDIANAPOLIS	79
ST VINCENT HEART CENTER OF INDIANA LLC	INDIANAPOLIS	79
SCOTT COUNTY MEMORIAL HOSPITAL	SCOTTSBURG	78
JAY COUNTY HOSPITAL	PORTLAND	78
CAMERON MEMORIAL COMMUNITY HOSPITAL INC	ANGOLA	78
GOOD SAMARITAN HOSPITAL	VINCENNES	78
THE HEART HOSPITAL AT DEACONESS GATEWAY LLC	NEWBURGH	77
WABASH COUNTY HOSPITAL	WABASH	77
PARKVIEW HUNTINGTON HOSPITAL	HUNTINGTON	77
MEMORIAL HOSPITAL	LOGANSPORT	77
ST VINCENT MERCY HOSPITAL	ELWOOD	77
MARION GENERAL HOSPITAL	MARION	77
SCHNECK MEDICAL CENTER	SEYMOUR	76
PARKVIEW HOSPITAL	FORT WAYNE	76
PARKVIEW WHITLEY HOSPITAL	COLUMBIA CITY	76
ST VINCENT FRANKFORT HOSPITAL INC	FRANKFORT	75
FAYETTE REGIONAL HEALTH SYSTEM	CONNERSVILLE	75
ST VINCENT CLAY HOSPITAL INC	BRAZIL	75
ST JOSEPH HOSPITAL	FORT WAYNE	74
DEKALB HEALTH	AUBURN	74
ST CATHERINE HOSPITAL INC	EAST CHICAGO	74
WOMEN'S HOSPITAL THE	NEWBURGH	74
MONROE HOSPITAL	BLOOMINGTON	74
INDIANA UNIVERSITY HEALTH STARKE HOSPITAL	KNOX	74
BLUFFTON REGIONAL MEDICAL CENTER	BLUFFTON	74
ST VINCENT DUNN HOSPITAL INC	BEDFORD	74
HENRY COUNTY MEMORIAL HOSPITAL	NEW CASTLE	74
PARKVIEW LAGRANGE HOSPITAL	LAGRANGE	73
SAINT JOSEPH REGIONAL MEDICAL CENTER	MISHAWAKA	73
MAJOR HOSPITAL	SHELBYVILLE	73
DUPONT HOSPITAL LLC	FORT WAYNE	73
DEARBORN COUNTY HOSPITAL	LAWRENCEBURG	73
HOWARD REGIONAL HEALTH SYSTEM	KOKOMO	73
COMMUNITY HOSPITAL	MUNSTER	73
ST MARY MEDICAL CENTER INC	HOBART	73
PARKVIEW NOBLE HOSPITAL	KENDALLVILLE	73
ST VINCENT CARMEL HOSPITAL INC	CARMEL	73
INDIANA HEART HOSPITAL THE	INDIANAPOLIS	73
PINNACLE HOSPITAL	CROWN POINT	73
FRANCISCAN ST FRANCIS HEALTH - INDIANAPOLIS	INDIANAPOLIS	72
FRANCISCAN ST FRANCIS HEALTH - MOORESVILLE	MOORESVILLE	72
DUKES MEMORIAL HOSPITAL	PERU	72
HARRISON COUNTY HOSPITAL	CORYDON	72
TERRE HAUTE REGIONAL HOSPITAL	TERRE HAUTE	72
SAINT JOSEPH'S REGIONAL MEDICAL CENTER - PLYMOUTH	PLYMOUTH	72
*State of Indiana Average*	***	71
HENDRICKS REGIONAL HEALTH	DANVILLE	71
FRANCISCAN ST ANTHONY HEALTH - MICHIGAN CITY	MICHIGAN CITY	71
IU HEALTH GOSHEN HOSPITAL	GOSHEN	71
FRANCISCAN PHYSICIANS HOSPITAL LLC	MUNSTER	71
ST VINCENT JENNINGS HOSPITAL INC	NORTH VERNON	71
INDIANA UNIVERSITY HEALTH ARNETT HOSPITAL	LAFAYETTE	71
WITHAM HEALTH SERVICES	LEBANON	70
RIVERVIEW HOSPITAL	NOBLESVILLE	70
THE ORTHOPAEDIC HOSPITAL OF LUTHERAN HEALTH NETWOR	FT WAYNE	70
MEMORIAL HOSPITAL AND HEALTH CARE CENTER	JASPER	70
HANCOCK REGIONAL HOSPITAL	GREENFIELD	70
ST MARY'S MEDICAL CENTER OF EVANSVILLE INC	EVANSVILLE	70
COLUMBUS REGIONAL HOSPITAL	COLUMBUS	70
KING'S DAUGHTERS' HOSPITAL AND HEALTH SERVICESTHE	MADISON	70
PORTER VALPARAISO HOSPITAL	VALPARAISO	70
COMMUNITY HOSPITAL OF ANDERSON AND MADISON COUNTY	ANDERSON	70
DAVIESS COMMUNITY HOSPITAL	WASHINGTON	70
ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH LLC	FORT WAYNE	70
SAINT JOHN'S HEALTH SYSTEM	ANDERSON	70
REID HOSPITAL & HEALTH CARE SERVICES	RICHMOND	70
ST VINCENT HOSPITAL & HEALTH SERVICES	INDIANAPOLIS	70
INDIANA UNIVERSITY HEALTH BALL MEMORIAL HOSPITAL	MUNCIE	69
CLARK MEMORIAL HOSPITAL	JEFFERSONVILLE	69
JOHNSON MEMORIAL HOSPITAL	FRANKLIN	69
LUTHERAN HOSPITAL OF INDIANA	FORT WAYNE	69
FLOYD MEMORIAL HOSPITAL AND HEALTH SERVICES	NEW ALBANY	69
DECATUR COUNTY MEMORIAL HOSPITAL	GREENSBURG	69
INDIANA UNIVERSITY HEALTH BEDFORD HOSPITAL	BEDFORD	69
FRANCISCAN ST FRANCIS HEALTH - BEECH GROVE	BEECH GROVE	68
ELKHART GENERAL HOSPITAL	ELKHART	68
GIBSON GENERAL HOSPITAL	PRINCETON	68
INDIANA UNIVERSITY HEALTH NORTH HOSPITAL	CARMEL	68
KOSCIUSKO COMMUNITY HOSPITAL	WARSAW	68
INDIANA UNIVERSITY HEALTH WEST HOSPITAL	AVON	68
UNITY MEDICAL AND SURGICAL HOSPITAL	MISHAWAKA	68
COMMUNITY HOSPITAL EAST	INDIANAPOLIS	68
UNION HOSPITAL CLINTON	CLINTON	68
WESTVIEW HOSPITAL	INDIANAPOLIS	68
FRANCISCAN ST ELIZABETH HEALTH - LAFAYETTE EAST	LAFAYETTE	68
ST VINCENT RANDOLPH HOSPITAL INC	WINCHESTER	67
ST JOSEPH HOSPITAL & HEALTH CENTER INC	KOKOMO	67
INDIANA UNIVERSITY HEALTH BLOOMINGTON HOSPITAL	BLOOMINGTON	67
DEACONESS HOSPITAL INC	EVANSVILLE	67
COMMUNITY HOSPITAL NORTH	INDIANAPOLIS	67
INDIANA UNIVERSITY HEALTH	INDIANAPOLIS	67
FRANCISCAN ST ANTHONY HEALTH - CROWN POINT	CROWN POINT	67
WILLIAM N WISHARD MEMORIAL HOSPITAL	INDIANAPOLIS	67
MEMORIAL HOSPITAL OF SOUTH BEND	SOUTH BEND	67
COMMUNITY HOSPITAL SOUTH	INDIANAPOLIS	67
INDIANA UNIVERSITY HEALTH PAOLI HOSPITAL	PAOLI	67
FRANCISCAN ST ELIZABETH HEALTH - LAFAYETTE CENTRAL	LAFAYETTE	67
INDIANA UNIVERSITY HEALTH TIPTON HOSPITAL INC	TIPTON	66
FRANCISCAN ST ELIZABETH HEALTH - CRAWFORDSVILLE	CRAWFORDSVILLE	66
FRANCISCAN ST MARGARET HEALTH - DYER	DYER	66
FRANCISCAN ST MARGARET HEALTH - HAMMOND	HAMMOND	65
INDIANA UNIVERSITY HEALTH MORGAN HOSPITAL INC	MARTINSVILLE	65
SULLIVAN COUNTY COMMUNITY HOSPITAL	SULLIVAN	65
UNION HOSPITAL INC	TERRE HAUTE	65
METHODIST HOSPITALS INC	GARY	64
ST VINCENT WILLIAMSPORT HOSPITAL INC	WILLIAMSPORT	63
INDIANA UNIVERSITY HEALTH LA PORTE HOSPITAL	LA PORTE	60
SAINT CATHERINE REGIONAL HOSPITAL	CHARLESTOWN	56

Schneck Medical Center (Seymour, IN) posts Baldrige Application Documents

2012-04-28T22:17:00.000-04:00

As required by all Baldrige Award winners, Schneck Medical Center has made portions of its Baldrige Application available to the public. Although the full application is not yet posted on the NIST website, most* of it can be found on the Schneck baldrige website.
Schneck Category 1 - Leadership
Schneck Category 2 - Strategic Planning
Schneck Category 3 - Focus on Patients
Schneck Category 4 - Measurement, Analysis, and Knowledge Management
Schneck Category 5 - Workforce Focus
Schneck Category 6 - Process Management

*As of April 28, 2012, the Organizational Profile and Category 7 (Results) have not yet been posted.

"Substantial Minority" of People Equate High Healthcare Costs with High Healthcare Quality

2012-03-31T18:11:00.000-04:00

The March 2012 issue of Health Affairs published an AHRQ funded study that found consumer selection of healthcare providers may gravitate towards higher cost options when clear quality information is not also presented. This is contrary to the intended outcome of the cost transparency movement in healthcare.

The AHRQ press release can be found here: http://www.ahrq.gov/news/press/pr2012/highvaluepr.htm

The Health Affairs abstract (and article for purchase) can be found here: http://content.healthaffairs.org/content/31/3/560.abstract

A powerpoint presentation summarizing this study's findings can be found here: http://www.ahrq.gov/about/annualconf11/hibbard_mehrotra/hibbard.pptx

The following are excerpts from the AHRQ press release associated with the publication of this study:

When asked to choose a health care provider based only on cost, consumers choose the more expensive option, according to a new study funded by HHS' Agency for Healthcare Research and Quality (AHRQ) that appears in the March issue of Health Affairs.

The study found that consumers equate cost with quality and worry that lower cost means lower quality care. But higher costs may indicate unnecessary services or inefficiencies, so cost information alone does not help consumers get the best value for their health care dollar, according to the study.

The study, entitled "An Experiment Shows That a Well-Designed Report on Costs and Quality Can Help Consumers Choose High-Value Health Care," found that when consumers were shown the right mix of cost and quality information, they were better able to choose high-value health care providers—defined as those who deliver high-quality care at a lower cost.

The study explored a number of ways to present cost and quality information effectively, using combinations of symbols such as dollar signs and stars, specific information such as dollar amounts and percentages, and labels such as "appropriate use" or "better." Consumers were more likely to choose high-value providers when presented with strong, unambiguous quality and cost information. In addition, a check mark indicating a "high-value" provider, along with the cost and quality information, also helped consumers use the information to make high-value choices. Given strong quality signals, consumers were also more confident in their choices.

Medicare Readmission Rates of Indiana Hospitals

2012-03-02T22:23:00.000-05:00

The Center for Medicare and Medicaid Services (CMS) releases on a quarterly basis the readmission rates of Medicare patients discharged with a diagnosis of acute myocardial infraction (heart attack), heart failure, or pneumonia. The table below shows the relative performance of all Indiana hospitals for these three measures. This data is from patients discharged from July 1, 2007 to March 31, 2011.
"-"        - No Different than US National Rate
"+1"       - Better than US National Rate
"-1"       - Worse than US National Rate
"Small n"  - Number of patients too small to determine performance

		Readmission Rates
Hospital Name	City	Heart Attack	Heart Failure	Pneumonia
ADAMS MEMORIAL HOSPITAL	DECATUR	-	-	-
BLUFFTON REGIONAL MEDICAL CENTER	BLUFFTON	-	-	-
CAMERON MEMORIAL COMMUNITY HOSPITAL INC	ANGOLA	Small n	-	-
CANCER CARE PARTNERS LLC	MISHAWAKA	N/A	N/A	N/A
CLARK MEMORIAL HOSPITAL	JEFFERSONVILLE	-	-	-
COLUMBUS REGIONAL HOSPITAL	COLUMBUS	-	-	-
COMMUNITY HOSPITAL	MUNSTER	-	-1	-
COMMUNITY HOSPITAL EAST	INDIANAPOLIS	-	-	-
COMMUNITY HOSPITAL NORTH	INDIANAPOLIS	Small n	-	-
COMMUNITY HOSPITAL OF ANDERSON AND MADISON COUNTY	ANDERSON	-	-	-
COMMUNITY HOSPITAL OF BREMEN INC	BREMEN	Small n	-	-
COMMUNITY HOSPITAL SOUTH	INDIANAPOLIS	-	-	-
DAVIESS COMMUNITY HOSPITAL	WASHINGTON	Small n	-	-
DEACONESS HOSPITAL INC	EVANSVILLE	-	-	-
DEARBORN COUNTY HOSPITAL	LAWRENCEBURG	-	-	-
DECATUR COUNTY MEMORIAL HOSPITAL	GREENSBURG	Small n	-	-
DEKALB HEALTH	AUBURN	Small n	-	-
DUKES MEMORIAL HOSPITAL	PERU	Small n	-	-
DUPONT HOSPITAL LLC	FORT WAYNE	Small n	-	-
ELKHART GENERAL HOSPITAL	ELKHART	-	-	-
FAYETTE REGIONAL HEALTH SYSTEM	CONNERSVILLE	-	-	-
FLOYD MEMORIAL HOSPITAL AND HEALTH SERVICES	NEW ALBANY	-	-	-
FRANCISCAN PHYSICIANS HOSPITAL LLC	MUNSTER	Small n	-	-
FRANCISCAN ST ANTHONY HEALTH - CROWN POINT	CROWN POINT	-	-	-
FRANCISCAN ST ANTHONY HEALTH - MICHIGAN CITY	MICHIGAN CITY	-	-	-
FRANCISCAN ST ELIZABETH HEALTH - CRAWFORDSVILLE	CRAWFORDSVILLE	Small n	-	-
FRANCISCAN ST ELIZABETH HEALTH - LAFAYETTE CENTRAL	LAFAYETTE	-	-	-
FRANCISCAN ST ELIZABETH HEALTH - LAFAYETTE EAST	LAFAYETTE	-	-	-
FRANCISCAN ST FRANCIS HEALTH - BEECH GROVE	BEECH GROVE	-	-	+1
FRANCISCAN ST FRANCIS HEALTH - INDIANAPOLIS	INDIANAPOLIS	-	-	-
FRANCISCAN ST FRANCIS HEALTH - MOORESVILLE	MOORESVILLE	Small n	-	-
FRANCISCAN ST MARGARET HEALTH - DYER	DYER	-	-	-
FRANCISCAN ST MARGARET HEALTH - HAMMOND	HAMMOND	-1	-1	-
GIBSON GENERAL HOSPITAL	PRINCETON	Small n	-	-
GOOD SAMARITAN HOSPITAL	VINCENNES	-	-	-
GREENE COUNTY GENERAL HOSPITAL	LINTON	Small n	-	-
HANCOCK REGIONAL HOSPITAL	GREENFIELD	-	-	-
HARRISON COUNTY HOSPITAL	CORYDON	Small n	-	-
HENDRICKS REGIONAL HEALTH	DANVILLE	-	+1	-
HENRY COUNTY MEMORIAL HOSPITAL	NEW CASTLE	Small n	-	-
HOWARD REGIONAL HEALTH SYSTEM	KOKOMO	-	-	-
INDIANA HEART HOSPITAL THE	INDIANAPOLIS	-	-	-
INDIANA ORTHOPAEDIC HOSPITAL LLC	INDIANAPOLIS	N/A	N/A	N/A
INDIANA UNIVERSITY HEALTH	INDIANAPOLIS	-	-	-
INDIANA UNIVERSITY HEALTH ARNETT HOSPITAL	LAFAYETTE	-	-	-
INDIANA UNIVERSITY HEALTH BALL MEMORIAL HOSPITAL	MUNCIE	+1	+1	+1
INDIANA UNIVERSITY HEALTH BEDFORD HOSPITAL	BEDFORD	-	-	-
INDIANA UNIVERSITY HEALTH BLACKFORD HOSPITAL	HARTFORD CITY	Small n	-	-
INDIANA UNIVERSITY HEALTH BLOOMINGTON HOSPITAL	BLOOMINGTON	-	-	-
INDIANA UNIVERSITY HEALTH LA PORTE HOSPITAL	LA PORTE	-	-	-
INDIANA UNIVERSITY HEALTH MORGAN HOSPITAL INC	MARTINSVILLE	-	-	-
INDIANA UNIVERSITY HEALTH NORTH HOSPITAL	CARMEL	-	-	-
INDIANA UNIVERSITY HEALTH PAOLI HOSPITAL	PAOLI	Small n	-	-
INDIANA UNIVERSITY HEALTH STARKE HOSPITAL	KNOX	Small n	-	-
INDIANA UNIVERSITY HEALTH WEST HOSPITAL	AVON	-	-	-
INDIANA UNIVERSITY HEALTH WHITE MEMORIAL HOSPITAL	MONTICELLO	Small n	-	-
INDIANAPOLIS VA MEDICAL CENTER	INDIANAPOLIS	-	-	-
IU HEALTH GOSHEN HOSPITAL	GOSHEN	-	-	-
JASPER COUNTY HOSPITAL	RENSSELAER	Small n	-	-
JAY COUNTY HOSPITAL	PORTLAND	Small n	-	-
JOHNSON MEMORIAL HOSPITAL	FRANKLIN	-	-	-
KENTUCKIANA MEDICAL CENTER LLC	CLARKSVILLE	Small n	Small n	Small n
KING'S DAUGHTERS' HOSPITAL AND HEALTH SERVICESTHE	MADISON	-	-	-
KOSCIUSKO COMMUNITY HOSPITAL	WARSAW	-	-	-
LUTHERAN HOSPITAL OF INDIANA	FORT WAYNE	+1	-	-
MAJOR HOSPITAL	SHELBYVILLE	Small n	-	-
MARGARET MARY COMMUNITY HOSPITAL INC	BATESVILLE	Small n	-	-
MARION GENERAL HOSPITAL	MARION	-	-	-
MEMORIAL HOSPITAL	LOGANSPORT	Small n	-	-
MEMORIAL HOSPITAL AND HEALTH CARE CENTER	JASPER	-	-	-
MEMORIAL HOSPITAL OF SOUTH BEND	SOUTH BEND	-	+1	-
METHODIST HOSPITALS INC	GARY	-	-1	-
MONROE HOSPITAL	BLOOMINGTON	Small n	-	-
ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH LLC	FORT WAYNE	N/A	N/A	N/A
PARKVIEW HOSPITAL	FORT WAYNE	-	+1	+1
PARKVIEW HUNTINGTON HOSPITAL	HUNTINGTON	Small n	-	-
PARKVIEW LAGRANGE HOSPITAL	LAGRANGE	Small n	-	-
PARKVIEW NOBLE HOSPITAL	KENDALLVILLE	Small n	-	-
PARKVIEW WHITLEY HOSPITAL	COLUMBIA CITY	Small n	-	-
PERRY COUNTY MEMORIAL HOSPITAL	TELL CITY	Small n	-	-
PHYSICIANS' MEDICAL CENTER LLC	NEW ALBANY	N/A	N/A	N/A
PINNACLE HOSPITAL	CROWN POINT	Small n	-	-
PORTER VALPARAISO HOSPITAL	VALPARAISO	-	-	-
PUTNAM COUNTY HOSPITAL	GREENCASTLE	Small n	-	-
REID HOSPITAL & HEALTH CARE SERVICES	RICHMOND	-	-	-
RIVERVIEW HOSPITAL	NOBLESVILLE	-	-	-
SAINT CATHERINE REGIONAL HOSPITAL	CHARLESTOWN	Small n	-	-
SAINT JOHN'S HEALTH SYSTEM	ANDERSON	-	-	-
SAINT JOSEPH REGIONAL MEDICAL CENTER	MISHAWAKA	-	+1	-
SAINT JOSEPH'S REGIONAL MEDICAL CENTER - PLYMOUTH	PLYMOUTH	-	-	-
SCHNECK MEDICAL CENTER	SEYMOUR	-	-	-
SCOTT COUNTY MEMORIAL HOSPITAL AKA SCOTT MEMORIAL	SCOTTSBURG	Small n	-	-
ST CATHERINE HOSPITAL INC	EAST CHICAGO	-	-1	-
ST JOSEPH HOSPITAL	FORT WAYNE	-	-	-
ST JOSEPH HOSPITAL & HEALTH CENTER INC	KOKOMO	Small n	-	-
ST MARY MEDICAL CENTER INC	HOBART	-	-	-
ST MARY'S MEDICAL CENTER OF EVANSVILLE INC	EVANSVILLE	-	-	-
ST MARY'S WARRICK HOSPITAL INC	BOONVILLE	Small n	-	-
ST VINCENT CARMEL HOSPITAL INC	CARMEL	Small n	-	-
ST VINCENT CLAY HOSPITAL INC	BRAZIL	Small n	-	-
ST VINCENT DUNN HOSPITAL INC	BEDFORD	-	-	-
ST VINCENT FRANKFORT HOSPITAL INC	FRANKFORT	Small n	-	-
ST VINCENT HEART CENTER OF INDIANA LLC	INDIANAPOLIS	-	+1	-
ST VINCENT HOSPITAL & HEALTH SERVICES	INDIANAPOLIS	-	-	-
ST VINCENT JENNINGS HOSPITAL INC	NORTH VERNON	Small n	-	-
ST VINCENT MERCY HOSPITAL	ELWOOD	Small n	-	-
ST VINCENT RANDOLPH HOSPITAL INC	WINCHESTER	Small n	-	-
ST VINCENT WILLIAMSPORT HOSPITAL INC	WILLIAMSPORT	Small n	-	-
SULLIVAN COUNTY COMMUNITY HOSPITAL	SULLIVAN	Small n	-	-
TERRE HAUTE REGIONAL HOSPITAL	TERRE HAUTE	-	-	-
THE HEART HOSPITAL AT DEACONESS GATEWAY LLC	NEWBURGH	-	-	Small n
THE ORTHOPAEDIC HOSPITAL OF LUTHERAN HEALTH NETWOR	FT WAYNE	N/A	N/A	N/A
TIPTON HOSPITAL	TIPTON	Small n	-	-
UNION HOSPITAL CLINTON	CLINTON	Small n	-	-
UNION HOSPITAL INC	TERRE HAUTE	-	-	-
UNITY MEDICAL AND SURGICAL HOSPITAL	MISHAWAKA	N/A	N/A	Small n
VA N. INDIANA HEALTHCARE SYSTEM - MARION	MARION	Small n	-	-
WABASH COUNTY HOSPITAL	WABASH	Small n	-	-
WESTVIEW HOSPITAL	INDIANAPOLIS	Small n	-	-
WILLIAM N WISHARD MEMORIAL HOSPITAL	INDIANAPOLIS	-	-	-
WITHAM HEALTH SERVICES	LEBANON	-	-	-
WOMEN'S HOSPITAL THE	NEWBURGH	N/A	N/A	N/A

At least 12 Indiana Hospitals Report Having No Central Line Infections

2012-02-28T15:46:00.000-05:00

In early February 2012, CMS made hospital central line associated blood stream infection (CLABSI) data available on its HospitalCompare website.

Of the 125 Indiana hospitals listed in HospitalCompare, 88 were eligible for CLABSI reporting. For various reasons (small n, no ICU in hospital, etc...), no rating was provided for 65 hospitals. Of the remaining 22 hospitals, 12 reported no infections.

The 12 Indiana hospitals are:

Hospital	City
ELKHART GENERAL HOSPITAL	ELKHART
WILLIAM N WISHARD MEMORIAL HOSPITAL	INDIANAPOLIS
FRANCISCAN ST FRANCIS HEALTH - BEECH GROVE	BEECH GROVE
PORTER VALPARAISO HOSPITAL	VALPARAISO
FLOYD MEMORIAL HOSPITAL AND HEALTH SERVICES	NEW ALBANY
REID HOSPITAL & HEALTH CARE SERVICES	RICHMOND
COMMUNITY HOSPITAL EAST	INDIANAPOLIS
DEACONESS HOSPITAL INC	EVANSVILLE
INDIANA UNIVERSITY HEALTH BALL MEMORIAL HOSPITAL	MUNCIE
COMMUNITY HOSPITAL	MUNSTER
ST VINCENT HEART CENTER OF INDIANA LLC	INDIANAPOLIS

CMS published this data based on 1Q2011 only. This measure is based on the CDC's NHSN data collection protocol.

ACO Update: Health Affairs Releases a Policy Brief

2012-02-06T18:52:00.000-05:00

On January 31, 2012, Health Affairs, a peer-reviewed monthly journal, released a six page Health Policy Brief providing an update of where the US healthcare industry is in its rapid evolution towards accountable care type organizations.

The .pdf of the policy brief can be downloaded here.

The value of this paper is not limited to just the historical overview provided. The authors also give a general overview of some of the ongoing issues of the ACO model (small savings, anti-trust issues, enrollment, etc...).

Readers looking to for deep technical details of ACOs will be disappointed with this paper. However, those looking for a general overview of the current status of the ACO evolution will find this paper informative.

HCAHPS: Top Indiana Hospitals for Patients responding "Definately Would Recommend the Hospital"

2012-01-30T15:55:00.001-05:00

CMS released its most recent "Hospital Compare" data set on 1/26/2012 covering acute inpatients discharges from 4/1/2010 to 3/31/2011.

Indiana hospitals continue to outperform the rest of the country in patients reporting favorable experiences. For the specific HCAHPS question about if the patient would recommend the hospital to friends and family, the national average is 70% responding "definitely Yes". Indiana hospitals average 73% responding "definitely yes".

The table below shows the top 20% of Indiana hospitals and their specific performance on this question.

Hospital Name	City	Percent "Definitely Yes"
INDIANA ORTHOPAEDIC HOSPITAL LLC	INDIANAPOLIS	93
ST VINCENT HEART CENTER OF INDIANA LLC	INDIANAPOLIS	91
THE HEART HOSPITAL AT DEACONESS GATEWAY LLC	NEWBURGH	88
KENTUCKIANA MEDICAL CENTER LLC	CLARKSVILLE	88
INDIANA HEART HOSPITAL THE	INDIANAPOLIS	86
PHYSICIANS' MEDICAL CENTER LLC	NEW ALBANY	86
WOMEN'S HOSPITAL THE	NEWBURGH	85
MARGARET MARY COMMUNITY HOSPITAL INC	BATESVILLE	85
HENDRICKS REGIONAL HEALTH	DANVILLE	84
ST VINCENT CARMEL HOSPITAL INC	CARMEL	83
INDIANA UNIVERSITY HEALTH NORTH HOSPITAL	CARMEL	83
ST JOSEPH HOSPITAL & HEALTH CENTER INC	KOKOMO	82
PARKVIEW LAGRANGE HOSPITAL	LAGRANGE	82
FRANCISCAN ST FRANCIS HEALTH - MOORESVILLE	MOORESVILLE	82
ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH LLC	FORT WAYNE	81
SAINT JOSEPH REGIONAL MEDICAL CENTER	MISHAWAKA	81
DUPONT HOSPITAL LLC	FORT WAYNE	81
COMMUNITY HOSPITAL NORTH	INDIANAPOLIS	81
ST MARY MEDICAL CENTER INC	HOBART	81

2012 Baldrige Examiner Training in Indiana

2012-01-30T14:01:00.000-05:00

The Partnership for Excellence (TPE), the local / regional Baldrige program for Indiana, has announced an examiner training session in Indiana for 2012. In 2011, training sessions were only available in Ohio.

Applicants to be TPE Baldrige Examiners will have a training session at the VHA Central office in Indianapolis (by the Fashion Mall) on November 15-16, 2012. Other sessions are available throughout Ohio and West Virginia over the next month as well.

You can learn more about TPE and the process to become a TPE Baldrige Examiner at: http://www.thepartnershipforexcellence.org/

Note that under the new eligibility rules for the National Baldrige award, organizations must first participate through their local Baldrige program (unless certain exceptions apply). A great way for organizations to start their Baldrige journey is to have a trained examiner within their organization.

New Baldrige Eligibility Rules Impacts Indiana Organizations

2011-12-29T18:14:00.000-05:00

On December 21, 2011, the national Baldrige program announced via its blog that the eligibility rules for 2012 have changed. Under the new rules, organizations interested in applying for the national Baldrige Award must meet six new conditions as follows:

Be a previous Baldrige Award recipient
Have received the top-tier award from an Alliance member award program within the past 5 years
Have received a site visit at the national level within the past 5 years
Have received a combined scoring band range of 8 or better (e.g., process band 4 and results band 4) in the past 5 years
Have 25% or more of your employees/staff outside of your organization's home state
Have no Alliance member program available for your organization.

This impacts interested Indiana organizations because Indiana now does have an Alliance member program available: The Partnership for Excellence.

In other words, if your organization is just getting started with the Baldrige journey, it generally must win The Partnership for Excellence's not yet named Indiana award before it can apply for the national Baldrige award.

Given the amount and type of assistance The Partnership for Excellence makes available to organizations, this change will likely accelerate the Baldrige learning curve for an organization rather than slow down or delay progress towards excellence.

You can learn more about The Partnership for Excellence at its website: http://www.thepartnershipforexcellence.org/html/home.htm

You can learn more about the national Baldrige program at its website: http://www.nist.gov/baldrige/

Release of 2010 Indiana Medical Errors Report Poorly Covered by Media

2011-12-28T22:46:00.000-05:00

Although dated for 11/7/2011, the 2010 Indiana Medical Error Report was released to the public on 11/28/2011.

The link to the press release is here.
The link to the report itself is here.
The link to the data tables (containing facility specific numbers) is here.

In the month since the release of this report, coverage from the media has been disappointing. A brief google scan of Indiana news coverage shows the following:

The Indy Star and WTHR carried the same small piece on 11/29/2011 highlighting that bed sores were the most commonly reported error and foreign objects left inside patients after surgery was the second. To it's credit, the report did not single out any hospital with high raw numbers.
However, on the day that the report was released, WTHR posted a separate story on its website highlighting that medical errors had reached a new high. Unfortunately, it reported raw numbers of events at various central Indiana facilities without any type of responsible interpretation. This story did attempt to offer readers advice on how to stay safe, however, the reporter clearly confused prevention concepts (surgery site marking, patient turning) with error reporting ("...what can you do if you suspect an error?).
On 12/2/2011, the Palladium-Item from Richmond, IN, carried a story highlighting the performance of its local hospital (Reid). It focused on the two patients that Reid reported fell in 2010 causing serious disability or death. It appears that the reporter (Pam Tharp) did interview hospital officials (a vice president, the director of patient safety and quality, and a spokesman) and provided quotes to balance the reported numbers. The story then proceeded to report the 5-Year reporting high, but noted possible explanations (changes in operational definitions) for this.
The Herald-Bulletin (Anderson), ran a story on 12/8/2011 describing the performance of the two area hospitals. The CEO of Community hospital provided detail of the hospitals process to minimize missing sponges and that it seeks to learn from its errors. The President of Saint John's Hospital and its CNO both provided similar detail as to how it prevents bed sores. Healthcare quality professionals will be happy to see that this article also noted that "Medical errors generally are not the sole result of people’s actions but rather the failure of the systems and processes used in providing health care... The requirement to report events identifies persistent problems, encourages increased awareness of patient safety issues and assists in the development of evidence-based initiatives to improve patient safety."

Of the above referenced coverage, it would appear that the reporter from the Herald-Bulletin (Abbey Dole) provided the most responsible reporting of the annual Medical Error report. With a story that could easily be irresponsibly covered to incite and inflame the public, this reporter educated the public on how the medical error reporting system helps healthcare in Indiana become safer.

CMS Approves ACO for Central Indiana

2011-12-20T15:23:00.001-05:00

Yesterday, CMS announced that 32 applications for Pioneer ACO from health systems across the country have been approved. The Franciscan Alliance was approved for the Indianapolis and Central Indiana region.

The press release from the Franciscan Alliance can be found here: http://stfrancisnews.blogspot.com/2011/12/franciscan-alliance-selected-to.html

The press release fact sheet from CMS announcing the 32 Pioneer ACOs can be found here: http://www.cms.gov/apps/media/press/factsheet.asp?Counter=4225

Over the past several months, the concept and model of an ACO has changed several times. This announcement is specifically for the Pioneer ACO model. Applications for the Advanced Payment Model is not due to CMS until Jan 2012.

This link will take you to a general resource about the Pioneer ACO Model: http://innovations.cms.gov/initiatives/aco/pioneer/

This link will take you to a general resource about the Advanced Payment ACO Model: http://innovations.cms.gov/initiatives/aco/advance-payment/

The most recent final rules from CMS concerning ACOs was published Oct 20, 2011. That document can be downloaded here: http://www.gpo.gov/fdsys/pkg/FR-2011-11-02/pdf/2011-27461.pdf

Healthcare quality professionals will be most interested in the list of 33 quality measures that will impact payments to ACOs. That list is on page 67889, or the 88th page into this above document.

Schneck Medical Center (Seymour, IN) Named 2011 Baldrige Award Recipient

2011-11-23T00:35:00.001-05:00

Schneck Medical Center of Seymour, Indiana, was named a 2011 Baldrige Award Recipient in the Healthcare Category. Schneck is the first organization from Indiana to receive the Baldrige Award.

Until recently, Indiana did not have a State level Baldrige-based award program. Schneck thus partnered with the Ohio Partnership for Excellence. The Ohio program has since expanded its scope and now covers the State of Indiana (as well as West Virginia). The program has now been renamed The Partnership for Excellence.

The press release announcing the other Baldrige Award winners can be found here.

The profile of Schneck Medical Center released with the announcement can be found here.

Below are excerpts from the profile of Schneck Medical Center outlining its quality performance that may be interesting to the healthcare quality professional. Note that the 50 page Baldrige application from Schneck will become public domain in a few months and thus awailable for public examination and learning. Schneck (as required by all Baldrige award winners) will also be participating in national and regional conferences where they will be sharing thier Baldrige journey.

SMC consistently demonstrates high levels of performance in relation to patient-focused health care measures. Specifically, on 17 of 22 core measures reported for the Centers for Medicare and Medicaid Services (CMS), SMC scored 100 percent in the second quarter of 2011.
SMC ranked second among 94 hospitals in its geographic region and outperformed all local competitors when measured for its value-based purchasing (VBP). VBP is a method that holds health care providers accountable for the quality and cost of their services through a system of rewards and consequences. Incentives discourage inappropriate, unnecessary, and costly care.
Patient satisfaction surveys reflect SMC’s year-to-year favorable performance, meeting or exceeding top 10 percent or top 25 percent levels on nine of 10 Press Ganey (a national consulting firm focused on improving health care performance) measures, including inpatient quality of care, inpatient family support, inpatient coordination of care, and inpatient customer service. On measures of ambulatory care, including timeliness, customer service, and ambulatory education, SMC’s performance exceeds the top 25 percent level.
SMC’s commitment to a “Patient First” culture has led to many innovative health care options. For example, to address its limited treatment options for myocardial infarctions, SMC and its largest competitor, located 25 miles away, created a collaborative initiative for coordinated handoffs of patients needing emergency cardiac catheterizations. Through this effort, “door-to-balloon” times (the critical period for assessing and diagnosing a heart attack and delivering the needed intervention) have been reduced from 120 to as low as 60 minutes, ensuring patients get the best and quickest treatment.
SMC has achieved high performance levels in all areas measured by the Hospital Consumer Assessment of Healthcare Providers and Systems, with SMC outperforming its Indiana peers from 2008 to 2011 (year-to-date) in the areas related to the ability of nurses and physicians to listen, understand, and provide clear discharge instructions.
SMC demonstrates role-model performance through its low overall rates of hospital-acquired infections, which have been maintained at or below 1 percent since 2008. There have been no occurrences of postoperative infections from bariatric surgeries, one of SMC’s focus areas. No patient has acquired ventilator-associated pneumonia since 2009, while central line-associated bloodstream infections have remained at low numbers since 2008, with zero cases in 2011 (year-to-date).
SMC demonstrates excellence in measures of its operating margin, cash flow, and cash position, with its reported results comparing favorably to the Standard & Poor’s (S&P) “A-” and “AA” rated median levels. From 2008 to 2010, SMC’s gross revenue results showed growth in the organization’s strategic focus areas—women’s health, joint replacement, noninvasive cardiac care, cancer care, and bariatric surgery.

Study Shows Baldrige Hospitals Perform Better than Non-Baldrige Hospitals

2011-11-02T16:11:00.000-04:00

Thomson Reuters recently released a research paper investigating the performance of Baldrige hospitals vs. non-Baldrige hospitals in key outcome measures. In this study, Baldrige hospitals were defined as hospitals that have won the Baldrige award or have publicly disclosed that they have received a site visit. Non-Baldrige hospitals were the remaining hospitals in the 100 Top Hospitals data set.

Of interest to healthcare quality professionals:

Baldrige hospitals were significantly more likley than their peers to display faster five-year performance improvement.
Baldrige hospitals performed better than their peers in the CMS core measures by 4.90 percantage points.

Although not statistically significant, the study also showed that Baldrige hospitals performed better on the following measures than their peers:

risk-adjusted mortality
patient safety index
severity-adjusted length of stay.
adjusted operating profit margin

The research paper can be downloaded from NIST here or from Thompson Reuters here.

The NIST press release associated with this research paper can be found here. For your convenience, excerpts from this press release have been copied and pasted below. Sections of interest to healthcare quality professionals are in red with some emphasis added.

New Study Finds that Baldrige Award Recipient Hospitals Significantly Outperform their Peers

A new report has found that healthcare organizations that have won Baldrige National Quality Awards for performance excellence or been considered for a Baldrige Award site visit outperform other hospitals in nearly every metric used to determine the 100 Top Hospitals, a national recognition given by Thomson Reuters.

Commissioned by the Foundation for the Malcolm Baldrige National Quality Award, a private organization, and conducted by Thomson Reuters, the report found that Baldrige hospitals were six times more likely to be counted among the 100 Top Hospitals, which represent the top 3 percent of hospitals in the United States, and that they statistically outperform the 100 Top Hospitals on core measures established by the U.S. Centers for Medicare & Medicaid Services.

Health care organizations have accounted for more than 50 percent of Baldrige award applicants since 2005.
Baldrige hospitals also were far more likely than their peers to be cited for marked improvement over a span of five years. According to the report, "[m]ore than 27 percent of Baldrige winner hospitals also won a 100 Top Hospitals: Performance Improvement Leaders award, while only 3 percent of their non-Baldrige peers won the award."

"The results of the Thomson Reuters study confirm what we've known for years: using the Baldrige Criteria and the earnest pursuit of the Baldrige evaluation will improve your organization by nearly every measure of success, be it in outcomes, safety, customer and employee satisfaction, or profitability," says Baldrige Performance Excellence Program Director Harry Hertz.

The study, Comparison of Baldrige Award Applicants and Recipients with Peer Hospitals on a National Balanced Scorecard, is available at www.nist.gov/baldrige/upload/baldrige-hospital-research-paper.pdf.

Indiana Hospitals Perform Extremely Well in the HCAHPS Overall Rating of Hospital Question

2011-10-31T20:18:00.000-04:00

CMS's October 2011 release of HCAHPS data covered the time period January 2010 to December 2010. The national average of % of patients who responded 9 or 10 to the overall rating of hospital question was 68%.

The state of Indiana, with an average of 73%, was tied as the 4th highest state in the country.

The top performing States are:
   1st:  IA - 75%
   2nd: KS - 74%
   2nd: NE - 74%
   4th: ID - 73%
   4th: IN - 73%
   4th: LA - 73%

Within the State of Indiana, 109 hospitals reported their performance on this question. Of these, 84 performned at the national average or higher. In other words, 77% of Indiana hospitals perform at or above the national average for the HCAHPS overall rating question.

The top three Indiana hospitals for this HCAHPS question are also specialty hospitals. They are:
   1st: Surgical Hospital of Munster (Munster) - 91%
   2nd: Indiana Orthopedic Hospital (Indianapolis)- 90%
   3rd: St.Vincent Heart Center of Indiana (Indianapolis)- 89%

Congratulations to Indiana hospitals for providing outstanding patient centric care!

Registry for Nursing Sensitive Patient Care - Is Everyone Doing It?

2011-10-31T18:21:00.001-04:00

Hospitals participating in the Hospital Inpatient Quality Reporting Program (IQR) for FY2012 are required (among other structural measures) to report their participation status in a "Systematic Clinical Database Registry for Nursing Sensitive Care". Hospitals are not required to participate in a registry, but to qualify for the annual payment update, they must report if they participate in one or not.

The most recent data released by CMS in October 2011 show that 51 Indiana hospitals reported "yes", 43 reported "no", and 24 were listed as "Not Available". Of these 24, only one was not a critical access hospital.

The following is the list of all Indiana hospitals that responded "Yes" to participating in a registry of nursing sensitive care:

BALL MEMORIAL HOSPITAL INC
COLUMBUS REGIONAL HOSPITAL
COMMUNITY HOSPITAL
COMMUNITY HOSPITAL EAST
COMMUNITY HOSPITAL NORTH
COMMUNITY HOSPITAL OF ANDERSON AND MADISON COUNTY
COMMUNITY HOSPITAL SOUTH
DEACONESS HOSPITAL INC
DEKALB HEALTH
FLOYD MEMORIAL HOSPITAL AND HEALTH SERVICES
FRANCISCAN ST ANTHONY HEALTH - CROWN POINT
FRANCISCAN ST ANTHONY HEALTH - MICHIGAN CITY
FRANCISCAN ST ELIZABETH HEALTH - LAFAYETTE CENTRAL
FRANCISCAN ST ELIZABETH HEALTH - LAFAYETTE EAST
FRANCISCAN ST FRANCIS HEALTH - BEECH GROVE
FRANCISCAN ST FRANCIS HEALTH - INDIANAPOLIS
FRANCISCAN ST FRANCIS HEALTH - MOORESVILLE
GOOD SAMARITAN HOSPITAL
HANCOCK REGIONAL HOSPITAL
HENDRICKS REGIONAL HEALTH
HOWARD REGIONAL HEALTH SYSTEM
INDIANA UNIVERSITY HEALTH
INDIANA UNIVERSITY HEALTH ARNETT HOSPITAL
INDIANA UNIVERSITY HEALTH BLOOMINGTON HOSPITAL
INDIANA UNIVERSITY HEALTH NORTH HOSPITAL
INDIANA UNIVERSITY HEALTH WEST HOSPITAL
IU HEALTH GOSHEN HOSPITAL
KING'S DAUGHTERS' HOSPITAL AND HEALTH SERVICESTHE
LAPORTE HOSPITAL AND HEALTH SERVICES
LUTHERAN HOSPITAL OF INDIANA
MAJOR HOSPITAL
MARION GENERAL HOSPITAL
MEMORIAL HOSPITAL
MEMORIAL HOSPITAL AND HEALTH CARE CENTER
ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH LLC
PARKVIEW HOSPITAL
PARKVIEW HUNTINGTON HOSPITAL
PARKVIEW LAGRANGE HOSPITAL
PARKVIEW NOBLE HOSPITAL
PARKVIEW WHITLEY HOSPITAL
REID HOSPITAL & HEALTH CARE SERVICES
SAINT JOSEPH REGIONAL MEDICAL CENTER
SAINT JOSEPH'S REGIONAL MEDICAL CENTER - PLYMOUTH
SCHNECK MEDICAL CENTER
ST CATHERINE HOSPITAL INC
ST MARY MEDICAL CENTER INC
ST MARY'S MEDICAL CENTER OF EVANSVILLE INC
ST VINCENT HOSPITAL & HEALTH SERVICES
TIPTON HOSPITAL
UNION HOSPITAL INC
WILLIAM N WISHARD MEMORIAL HOSPITAL

Indiana's State Level Baldrige Program

2011-07-31T21:31:00.001-04:00

Until last week, Indiana was one of the few remaining states without a Baldrige based award program. However, through the efforts of various interested groups and individuals throughout the state, and in collaboration with the Ohio Partnership for Excellence (OPE), Ohio's Baldrige based program, Indiana is no longer without.

Reflective of the strategy of the National Baldrige program to develop strong regional programs rather than each state having an independent program, Ohio recently announced its expansion into Indiana and West Virginia.

Although the details of the Indiana program is still being worked out, several Indiana individuals and organizations have already been involved with the OPE in previous years. In fact, Schneck Medical Center (Seymour, IN) will be presenting at OPE's "2011 Quest for Success" Conference coming up in September.

Link to Ohio Partnership for Excellence: http://www.partnershipohio.org/
Link to details of expansion into Indiana: http://www.partnershipohio.org/html/apply/apply_program_IN_&_WV.htm

The full text of the OPE press release follows:

Press Release

July 26, 2011

FOR IMMEDIATE RELEASE

Ohio Partnership for Excellence to Expand Programs to Indiana & West Virginia

COLUMBUS, OH – The Ohio Partnership for Excellence (OPE) is now approved to offer its Baldrige-based programs to organizations in Indiana and West Virginia. The Alliance for Performance Excellence approved the expansion after a nation-wide competitive process that included proposals from a number of states. The Alliance is a non-profit network of national, state and local Baldrige-based award programs, associated with the American Society for Quality and the U.S. Department of Commerce's National Institute of Standards & Technology that administers the Malcolm Baldrige National Quality Award.

OPE is Ohio's Baldrige-based award program that administers and presents the Ohio Awards for Excellence, including the Governor's Award for Excellence. OPE partners with organizations using the internationally-recognized Baldrige Criteria for Performance Excellence. OPE’s primary product is a comprehensive organizational assessment that helps leaders better understand and prioritize key strengths and opportunities for improvement. While the assessment lays the foundation, OPE’s main focus is on organizational learning, resource optimization and continuous improvement.

Under the visionary leadership of OPE's Board Chairman Frank Pérez, former President & CEO of the Kettering Health Network in Dayton and Paul Worstell, former President of PRO-TEC Coating Company in Leipsic, OPE has worked tirelessly to develop a strategy which will give Indiana and West Virginia organizations the same great opportunities OPE has afforded Ohioans for more than a decade. With this decision, OPE will grow into a regionalized program throughout all three states.

The mission of OPE is to cultivate performance excellence and continuous improvement among business, education, government, healthcare and non-profit organizations. By providing a framework for performance excellence through the Baldrige Criteria, organizations have a greater focus on customers, process management, work systems and organization-wide results. These organizations typically see lower costs, improved productivity and rises in both employee and customer satisfaction.

This year's OPE Award recipients will be honored at the annual Quest for Success Conference - “Harvesting Excellence” to be held on September 19-20 at Cherry Valley Lodge, Newark, Ohio. The two-day conference will feature four of the seven 2010 Malcolm Baldrige National Quality Award recipients and will provide numerous opportunities to learn about role-model performance management practices, share great ideas with colleagues, and benchmark world-class results.

For additional information please visit the OPE website at www.partnershipohio.org or contact Al Faber, President/CEO, Ohio Partnership for Excellence, 829 Bethel Road, #212, Columbus, OH 43214 or phone (614) 425-7157.

Performance of Indiana Hospitals on Patient Experience of Care Measures for Value Based Purchasing

2011-04-30T12:46:00.003-04:00

The following table shows the performance of Indiana hospitals on the HCAHPS measures CMS has indicated will be a part of the Value Based Purchasing program. This table is based on HospitalCompare data released April 11, 2011based on data collected from April 2009 to March 2010.

(Note: You may need to click on the image to open it in a new browser.)

CMS Announces final details of Value Based Purchasing for Inpatient Acute Care

2011-04-30T11:43:00.001-04:00

On April 29th, CMS announced the final rules of its upcoming Value Based Purchasing program for Inpatient Acute Care. This long anticipated program transitions the inpatient care provided to Medicare beneficaries from "pay for reporting" to "pay for performance".

The HHS press release itself is of little value to the healthcare quality professional. You can view it here: http://www.hhs.gov/news/press/2011pres/04/20110429a.html. However, it links to a CMS press release that contained more details. You can view it here: http://www.cms.gov/apps/media/press/factsheet.asp?Counter=3947.

Although these rules become effective with fiscal year 2013, CMS also released the list of measures for 2014 as well.

The following are excerpts from the CMS press release:

PERFORMANCE SCORING:

Performance Period: CMS has established a performance period that runs from July 1, 2011 through March 31, 2012, for the FY 2013 Hospital VBP payment determination. CMS anticipates that in future program years, if it becomes feasible, it may propose to use a full year as the performance period.

Scoring Methods: CMS will score each hospital based on achievement and improvement ranges for each applicable measure. A hospital’s score on each measure will be the higher of an achievement score in the performance period or an improvement score, which is determined by comparing the hospital’s score in the performance period with its score during a baseline period.

For scoring on achievement, hospitals will be measured based on how much their current performance differs from all other hospitals’ baseline period performance. Points will then be awarded based on the hospital’s performance compared to the threshold and benchmark scores for all hospitals. Points will only be awarded for achievement if the hospital’s performance during the performance period exceeds a minimum rate called the “threshold,” which is defined by CMS as the 50th percentile of hospital scores during the baseline period.

For scoring on improvement, hospitals will be assessed based on how much their current performance changes from their own baseline period performance. Points will then be awarded based on how much distance they cover between that baseline and the benchmark score. Points will only be awarded for improvement if the hospital’s performance improved from their performance during the baseline period.

Finally, CMS will calculate a Total Performance Score (TPS) for each hospital by combining the greater of its achievement or improvement points on each measure to determine a score for each domain, multiplying each domain score by the proposed domain weight and adding the weighted scores together. In FY 2013, the clinical process of care domain will be weighted at 70 percent and the patient experience of care domain will be weighted at 30 percent.

Incentive Payment Calculations: CMS will utilize a linear exchange function to calculate the percentage of value-based incentive payment earned by each hospital. Those hospitals that receive higher Total Performance Scores will receive higher incentive payments than those that receive lower Total Performance Scores. CMS will notify each hospital of the estimated amount of its value-based incentive payment for FY 2013 through its QualityNet account at least 60 days prior to Oct. 1, 2012. CMS will notify each hospital of the exact amount of its value-based incentive payment on Nov. 1, 2012.

FISCAL YEAR 2013 MEASURES

Clinical Process of Care Measures
AMI-7a - Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
AMI-8a - Primary PCI Received Within 90 Minutes of Hospital Arrival
HF-1 - Discharge Instructions
PN-3b - Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital
PN-6 - Initial Antibiotic Selection for CAP in Immunocompetent Patient
SCIP-Inf-1 - Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
SCIP-Inf-2 - Prophylactic Antibiotic Selection for Surgical Patients
SCIP-Inf-3 - Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
SCIP-Inf-4 - Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose
SCIP-Card-2 - Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period
SCIP-VTE-1 - Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
SCIP-VTE-2 - Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery

Patient Experience of Care Measures (HCAHPS)
· Communication with Nurses
· Communication with Doctors
· Responsiveness of Hospital Staff
· Pain Management
· Communication About Medicines
· Cleanliness and Quietness of Hospital Environment
· Discharge Information
· Overall Rating of Hospital

ADDITIONAL MEASURES FINALIZED FOR FY2014

Mortality Measures:
· Mortality-30-AMI: Acute Myocardial Infarction (AMI) 30-day Mortality Rate
· Mortality-30-HF: Heart Failure (HF) 30-day Mortality Rate
· Mortality-30-PN: Pneumonia (PN) 30-Day Mortality Rate

Hospital Acquired Condition Measures:
· Foreign Object Retained After Surgery
· Air Embolism
· Blood Incompatibility
· Pressure Ulcer Stages III & IV
· Falls and Trauma: (Includes: Fracture, Dislocation, Intracranial Injury, Crushing Injury, Burn, Electric Shock)
· Vascular Catheter-Associated Infections
· Catheter-Associated Urinary Tract Infection (UTI)
· Manifestations of Poor Glycemic Control

AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs), and Composite Measures:
· Complication/patient safety for selected indicators (composite)
· Mortality for selected medical conditions (composite)

Unadjusted "Fall and Trauma" Rates for Hospitals in Indiana

2011-04-17T22:01:00.001-04:00

On April 6, 2011, CMS released a spreadsheet linked to its Hospital Compare website showing the frequency of the eight (8) Hospital Acquired Conditions (HAC) in hospitals participating in the Medicare Program. This data set is of Medicare beneficiaries only, is not risk adjusted for the severity of the patients, and is based on administrative data only for patients discharged between Oct 1, 2008 to June 30, 2010.

The data can be downloaded from CMS here.

The table below shows the performance of the listed Indiana hospitals for the "Fall and Trauma" measure sorted from high to low.


Hospital name	Rate (per 1,000 discharges)	Number of eligible discharges (Denominator)	Number of HACs (Numerator)	National HAC rate (per 1,000 discharges)
UNITY MEDICAL AND SURGICAL HOSPITAL	7.634	131	1	0.564
RIVERVIEW HOSPITAL	2.428	3707	9	0.564
THE HEART HOSPITAL AT DEACONESS GATEWAY LLC	1.878	1065	2	0.564
SAINT CATHERINE REGIONAL HOSPITAL	1.641	1219	2	0.564
FAYETTE REGIONAL HEALTH SYSTEM	1.553	1932	3	0.564
REID HOSPITAL & HEALTH CARE SERVICES	1.257	9549	12	0.564
FRANCISCAN PHYSICIANS HOSPITAL LLC	1.233	811	1	0.564
MEMORIAL HOSPITAL OF SOUTH BEND	1.205	9955	12	0.564
ST. CLARE MEDICAL CENTER	1.179	1697	2	0.564
WITHAM HEALTH SERVICES	1.174	1704	2	0.564
KOSCIUSKO COMMUNITY HOSPITAL	1.084	2767	3	0.564
PARKVIEW HUNTINGTON HOSPITAL	1.065	939	1	0.564
INDIANA UNIVERSITY HEALTH ARNETT HOSPITAL	1.02	4904	5	0.564
MARION GENERAL HOSPITAL	0.962	4158	4	0.564
HENRY COUNTY MEMORIAL HOSPITAL	0.957	3134	3	0.564
BLUFFTON REGIONAL MEDICAL CENTER	0.944	2118	2	0.564
CLARK MEMORIAL HOSPITAL	0.932	8581	8	0.564
INDIANA UNIVERSITY HEALTH NORTH HOSPITAL	0.906	3313	3	0.564
COMMUNITY HOSPITAL NORTH	0.9	6664	6	0.564
ST. FRANCIS HOSPITAL - BEECH GROVE	0.853	9377	8	0.564
THE ORTHOPAEDIC HOSPITAL	0.788	1269	1	0.564
ST. VINCENT CARMEL HOSPITAL, INC.	0.767	2609	2	0.564
ST. MARGARET MERCY - DYER	0.725	5515	4	0.564
WESTVIEW HOSPITAL	0.7	1429	1	0.564
INDIANA UNIVERSITY HEALTH WEST HOSPITAL	0.689	4352	3	0.564
ELKHART GENERAL HOSPITAL	0.676	8879	6	0.564
GOOD SAMARITAN HOSPITAL	0.641	6241	4	0.564
DEARBORN COUNTY HOSPITAL	0.617	3239	2	0.564
DUPONT HOSPITAL LLC	0.603	1658	1	0.564
BALL MEMORIAL HOSPITAL INC	0.591	11840	7	0.564
METHODIST HOSPITALS, INC	0.588	13602	8	0.564
ST. CATHERINE HOSPITAL, INC	0.576	5211	3	0.564
INDIANA ORTHOPAEDIC HOSPITAL LLC	0.565	1770	1	0.564
COMMUNITY HOSPITAL	0.557	16165	9	0.564
COMMUNITY HOSPITAL SOUTH, INC.	0.549	5468	3	0.564
SAINT ANTHONY MEDICAL CENTER	0.545	9179	5	0.564
SAINT JOSEPH REGIONAL MEDICAL CENTER - SOUTH BEND	0.541	11100	6	0.564
LUTHERAN HOSPITAL OF INDIANA	0.535	13088	7	0.564
INDIANA HEART HOSPITAL, THE	0.528	3791	2	0.564
ST. MARY'S MEDICAL CENTER OF EVANSVILLE INC	0.514	11672	6	0.564
GOSHEN GENERAL HOSPITAL	0.489	4088	2	0.564
PORTER HOSPITAL, LLC, VALPARAISO HOSP CAMPUS	0.481	10389	5	0.564
PARKVIEW HOSPITAL	0.465	10748	5	0.564
MAJOR HOSPITAL	0.457	2189	1	0.564
BLOOMINGTON HOSPITAL	0.445	8981	4	0.564
ST. FRANCIS HOSPITAL - MOORESVILLE	0.435	2299	1	0.564
DEACONESS HOSPITAL INC	0.422	18959	8	0.564
SCHNECK MEDICAL CENTER	0.421	2378	1	0.564
JOHNSON MEMORIAL HOSPITAL	0.421	2378	1	0.564
TERRE HAUTE REGIONAL HOSPITAL	0.411	4861	2	0.564
MEMORIAL HOSPITAL AND HEALTH CARE CENTER	0.385	5190	2	0.564
UNION HOSPITAL INC	0.383	13057	5	0.564
ST. JOSEPH HOSPITAL	0.381	2626	1	0.564
FLOYD MEMORIAL HOSPITAL AND HEALTH SERVICES	0.375	10678	4	0.564
WILLIAM N WISHARD MEMORIAL HOSPITAL	0.368	5431	2	0.564
ST. VINCENT HOSPITALS AND HEALTH SERVICES	0.358	19569	7	0.564
CLARIAN HEALTH PARTNERS, INCORPORATED	0.321	28027	9	0.564
ST. FRANCIS HOSPITAL - INDIANAPOLIS	0.313	6388	2	0.564
COLUMBUS REGIONAL HOSPITAL	0.296	6766	2	0.564
THE KING'S DAUGHTERS' HOSPITAL AND HEALTH SERVICES	0.28	3574	1	0.564
ST. ELIZABETH EAST	0.244	4090	1	0.564
COMMUNITY HOSPITAL EAST	0.244	8195	2	0.564
LA PORTE HOSPITAL AND HEALTH SERVICES	0.235	4263	1	0.564
ST. MARGARET MERCY HEALTHCARE CENTERS - HAMMOND	0.228	8754	2	0.564
ST. MARY MEDICAL CENTER, INC.	0.224	8912	2	0.564
ST. ELIZABETH CENTRAL	0.219	4558	1	0.564
COMMUNITY HOSPITAL OF ANDERSON AND MADISON COUNTY	0.179	5601	1	0.564
SAINT JOHN'S HEALTH SYSTEM	0.169	5918	1	0.564
SAINT ANTHONY MEMORIAL HEALTH CENTER	0	5335	0	0.564
KENTUCKIANA MEDICAL CENTER LLC	0	619	0	0.564
MEMORIAL HOSPITAL	0	1480	0	0.564
HENDRICKS REGIONAL HEALTH	0	3423	0	0.564
DAVIESS COMMUNITY HOSPITAL	0	1727	0	0.564
HOWARD REGIONAL HEALTH SYSTEM	0	4148	0	0.564
PHYSICIANS' MEDICAL CENTER LLC	0	180	0	0.564
SURGICAL HOSPITAL OF MUNSTER	0	31	0	0.564
ST. JOSEPH HOSPITAL & HEALTH CENTER, INC	0	3856	0	0.564
PINNACLE HOSPITAL	0	542	0	0.564
HANCOCK REGIONAL HOSPITAL	0	2989	0	0.564
MONROE HOSPITAL	0	1335	0	0.564
ST. VINCENT HEART CENTER OF INDIANA, LLC	0	5756	0	0.564
WOMEN'S HOSPITAL, THE	0	114	0	0.564
PARKVIEW WHITLEY HOSPITAL	0	807	0	0.564
STARKE MEMORIAL HOSPITAL	0	785	0	0.564
PARKVIEW NOBLE HOSPITAL	0	1175	0	0.564
SAINT JOSEPH REGIONAL MEDICAL CENTER - PLYMOUTH	0	1773	0	0.564
DEKALB MEMORIAL HOSPITAL INC	0	1100	0	0.564
MORGAN HOSPITAL AND MEDICAL CENTER	0	1472	0	0.564
ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH LLC	0	1039	0	0.564

ACOs are here! ...but will it be everywhere?

2011-04-17T21:15:00.001-04:00

Details of the long awaited CMS ACO proposed rules were released on March 31, 2011 and posted in the April 7, 2011 edition of the Federal Register.

The Federal Register entry can be found here.

The Centers for Medicare and Medicaid Services also simultaneously posted fact sheets and other resources about the proposed ACOs rules:

No doubt there will be significant commentary provided by healthcare organizations throughout the country over the next few months. The comment period closes on June 6, 2011. ACO final rules go into effect January 1, 2012.

Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care

2011-02-13T20:44:00.000-05:00

Last week the Institute for Healthcare Improvement (IHI) released a white paper describing current frameworks of providing patient centric care. Within the document is also an assessment of primary and secondary drivers as well as descriptions of practices at exemplar organizations.

This IHI white paper can be download here.

The following are excerpts from IHI's document description:

In response to growing interest from the hospital community in better understanding and improving the experience of patients and their families during hospitalization, the Institute for Healthcare Improvement (IHI) conducted an in-depth review of the research, studied exemplar organizations, and interviewed experts in the field. Our aim was to identify the primary and secondary drivers of exceptional patient and family inpatient hospital experience (defined as care that is patient centered, safe, effective, timely, efficient, and equitable), as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey’s “willingness to recommend” the hospital.

The project identified five primary drivers of exceptional patient and family inpatient hospital experience of care: leadership; staff hearts and minds; respectful partnership; reliable care; and evidence-based care.

Ambulatory Surgery Centers (ASCs) & Healthcare Reform

2011-01-22T08:21:00.004-05:00

With the upcoming health care reform changes, ASCs can prove to be valuable in containing costs for all. See ASC Campaign for Advancing Surgical Care site for information on their initiatives:

http://advancingsurgicalcare.com/index.cfm/asc-policy/initiatives/