Indiana Healthcare Quality

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

Infographic: The Hazards of Hospitals

2011-09-07T10:18:00.000-04:00

An interesting infographic was recently posted at http://www.medicalbillingandcodingcertification.net/ showing data related to sources of harm in hospitals. The image is below.

Created by: Medical Billing and Coding

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/

FAQ on ACOs

2011-01-16T20:25:00.000-05:00

Discussions of Accountable Care Organizations (ACOs) are sure to dominate the minds of hospital and health plan administrators in the next few months/years. The establishment of these entities will likely impact the work and expectations of health care quality professionals. Kaiser Health News recently posted an ACO FAQ list. You can find it here.

This FAQ provides thoughts to the following questions:

What is an accountable care organization?
When will ACOs begin operating?
Why did Congress include ACOs in the law?
How would ACOs be paid?
How will an ACO be different for patients?
Who's in charge — hospitals, doctors or insurers?
If I don't like HMOs, why should I consider an ACO?
What can go wrong?
Are there any possible legal concerns?

CMS Proposes Value Based Purchasing Program Rules for Hospital Inpatient

2011-01-10T00:01:00.000-05:00

On Friday, CMS announced its highly anticipated proposed rules for its new hospital value based purchasing program. The pdf of the proposed rules can be found here: http://www.ofr.gov/OFRUpload/OFRData/2011-00454_PI.pdf
(Note: this link will not likely become live until 1/13/2011).

Although these are "new" proposed rules, there are really no surprises in terms of payment methodology. The amount "at risk" due to poor performance is probably lower than what was initially expected (ie: 1-2% rather than 4-5%).

The following are excerpts from the CMS press release and fact sheet that may be of interest:

Under the program, hospitals that perform well on quality measures relating both to clinical process of care and to patient experience of care, or those making improvements in their performance on those measures, would receive higher payments.
The financial incentives would be funded by a reduction in the base operating DRG payments for each discharge, which under the statute will be 1% in FY 2013, rising to 2% by FY 2017.
CMS will accept comments on the hospital value-based purchasing Program proposed rule until March 8, 2010, and will respond to them in a final rule to be issued next year.
For the FY 2013 hospital value-based purchasing program, CMS proposes to use 17 clinical process of care measures as well as 8 measures from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that document patients’ experience of care.
CMS also proposes to adopt three mortality outcome measures, eight Hospital Acquired Condition (HAC) measures, and nine Agency for Healthcare Research and Quality (AHRQ) measures for the FY 2014 Hospital VBP program.
Proposed Performance Period: As required by the Affordable Care Act, CMS is proposing a performance period that ends prior to the beginning of FY 2013, specifically from July 1, 2011 through March 31, 2012, for the FY 2013 hospital value-based purchasing payment determination. CMS anticipates that in future fiscal years, the Agency may propose to use a full year as the performance period. In addition, CMS is proposing to use an 18-month performance period for the three proposed mortality measures for the FY 2014 Hospital VBP payment determination, and expects to propose a performance period for the eight HAC and nine AHRQ measures in future rulemaking.
Proposed Scoring Methods: CMS proposes to score each hospital on relative achievement and improvement ranges for each applicable measure. A hospital’s performance on each quality measure would be evaluated based on 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 of performance. For each of the proposed clinical process and patient experience of care measures that apply to a hospital for FY 2013, CMS proposes that a hospital would earn 0-10 points for achievement based on where its performance for the measure fell within an achievement range, which is a scale between an achievement threshold and a benchmark. With regard to the improvement score, CMS proposes that a hospital would earn 0-9 points based on how much its performance on the measure during the performance period improved from its performance on the measure during the baseline period. Finally, CMS would calculate a Total Performance Score (TPS) for each hospital by combining its scores on all of the measures within each domain, multiplying its performance score on each domain by the proposed weight for the domain, and adding the weighted scores for the domains.
Proposed Incentive Payment Calculations: CMS proposes to translate each hospital’s TPS into a value-based incentive payment using a linear exchange function. The linear exchange function provides the same marginal incentives to both lower- and higher-performing hospitals.
CMS proposes to 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 proposes to notify each hospital of the exact amount of its value-based incentive payment on or about Nov. 1, 2012.
CMS will accept public comments on the proposed rule through March 8, 2010 CMS will review all comments and respond to them in a final Hospital VBP rule scheduled to be released some time in 2011.

PROPOSED QUALITY MEASURES FY2013
AMI-2: Aspirin Prescribed at Discharge
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
HF-2: Evaluation of LVS Function
HF-3: ACEI or ARB for LVSD

PN-2: Pneumococcal Vaccination
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
PN-7: Influenza Vaccination
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 Pts. on a Beta Blocker Prior to Arrival...
SCIP-VTE-1: Surgery Pts. with Recommended Venous Thromboembolism Prophylaxis Ordered
SCIP-VTE-2: Surgery Pts. Who Received Appropriate Venous Thromboembolism Prophylaxis...

HCAHPS: Communication with Nurses
HCAHPS: Communication with Doctors
HCAHPS: Responsiveness of Hospital Staff
HCAHPS: Pain Management
HACHPS: Communication About Medicines
HACHPS: Cleanliness and Quietness of Hospital Environment
HACHPS: Discharge Information
HACHPS: Overall Rating of Hospital

PROPOSED ADDITIONAL QUALITY MEASURES FOR FISCAL YEAR 2014

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

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

PSI 06 – Iatrogenic pneumothorax, adult
PSI 11 – Post Operative Respiratory Failure
PSI 12 – Post Operative PE or DVT
PSI 14 – Post Operative would dehiscence
PSI 15 – Accidental puncture or laceration
IQI 11 – Abdominal aortic aneurysm (AAA) repair mortality rate (with or without volume)
IQI 19 – Hip fracture mortality rate

Complication/patient safety for selected indicators (composite)
Mortality for selected medical conditions (composite)

Be a Baldrige Examiner in 2011

2010-12-05T21:34:00.000-05:00

Baldrige Examiners contribute to the process of determining each year's Baldrige Award recipients. Last year, 1/3 of all examiners were from the healthcare industry.

Why is the Baldrige Criteria for performance excellence so important to healthcare? Rulon Stacy, the CEO for Pouder Valley Health Systems says that "...as soon as you become a Baldrige organization, it will cost you less to run your business, and your outcomes will be better."

Organizations will a Baldrige Examiner on staff will have a unique resource that will give them insight on how to best align themselves to the Baldrige criteria to improve their performance.

Applications for next year's Baldrige Board of Examiners are being accepted until January 13, 2011.

You can learn more about the Baldrige Criteria here: http://www.nist.gov/baldrige/
You can learn more about the examiner application process here: http://www.nist.gov/baldrige/examiners/index.cfm

Berwick Testifies to the Senate Finance Committee

2010-11-28T19:33:00.000-05:00

On November 17th, Donald Berwick testified before the Senate Finance Committee. As you can imagine, there was a lot of political tension surrounding this event.

The video of the entire senate hearing is here: http://finance.senate.gov/hearings/watch/?id=280ebc81-5056-a032-5254-1010c1e9b945

Berwick's prepared statement can be found here: http://finance.senate.gov/imo/media/doc/FINAL%20Donald%20Berwick%20Testimony%2011.15.101.pdf

Bacus' prepared opening statement can be found here: http://finance.senate.gov/imo/media/doc/11172010%20Baucus%20Hearing%20Statement%20Regarding%20New%20Patient%20Protections%20to%20Strengthen%20Medicare%20and%20Medicaid1.pdf

Grassley's prepared opening statement can be found here: http://finance.senate.gov/imo/media/doc/health%20care%2011-17-10%20hearing%20with%20Dr.pdf

Kaiser Health News, a program of the Kaiser Family Foundation, consolidated a resource page about Dr. Donald Berwick. It contains both what he has said as well as what others have said about him (and what he said). It can be found here: http://www.kaiserhealthnews.org/Stories/2010/June/30/Donald-Berwick-Resource-Guide.aspx

RAC for Medicaid?

2010-11-09T20:41:00.004-05:00

The following is a press release from CMS (Nov 5, 2010) announcing some of the details for the implementation of Medicaid RAC. Items of interest to quality professionals are in red.

MEDICAID RECOVERY AUDIT CONTRACTORS RULE ANNOUNCED TO HELP REDUCE IMPROPER PAYMENTS
CMS ANNOUNCES EDUCATION EFFORT TO SUPPORT PROGRAM

The Centers for Medicare & Medicaid Services (CMS) today proposed new rules to help states reduce improper payments for Medicaid health care claims through the use of Medicaid Recovery Audit Contractors (RACs) as part of the Affordable Care Act’s larger strategy to crack down on waste, fraud and abuse in the health care system. Medicaid RACs are contractors, working for States, that will audit payments made to health care providers to identify Medicaid payments that may have been underpaid or overpaid, and recover overpayments or correct underpayments, similar to the RAC program in Medicare.

“Reducing improper payments is a key goal of the Administration, and the tools provided by the Affordable Care Act will help us achieve that goal,” said CMS Administrator Donald Berwick, M.D. “We are using many of the lessons that we learned from the Medicare RAC program in the development and implementation of the Medicaid RACs, including a far-reaching education effort for health care providers and State managers.”

Under the Affordable Care Act, States must establish Medicaid RAC programs by submitting state plan amendments to CMS by December 31, 2010. The law allows CMS to provide extensions or exceptions to States, if necessary, and details regarding these processes are included in the proposed regulation. In addition, the proposed regulation issued by CMS today outlines the requirements that states must meet and the Federal contribution CMS will provide to assist in funding the state RAC programs.

Medicaid RACs will be paid by the States on a contingency basis to review Medicaid provider claims, identify and recover overpayments made for services provided under Medicaid State plans and Medicaid waivers. The proposed regulation allows States the discretion to determine whether to pay their Medicaid RACs on a contingency basis or under some other fee structure for identifying underpayments.

CMS is encouraging interested parties to comment on the proposals included in the regulation. These include the payment methodology for identifying overpayments and underpayments as well as the recovery of overpayments and correction of underpayments, and the requirement that RACs report fraud or criminal activity whenever they have reasonable grounds to believe such activity has occurred.

Under the regulation, as proposed, a State may use its current administrative appeals process or may modify its process for Medicaid RAC-related appeals. All fees paid to the Medicaid RACs must come from amounts recovered after all available appeals have been exhausted.

Because CMS has proposed to require States to implement their programs in a timely manner, CMS is providing educational programs to help States understand both the Medicare and Medicaid RAC programs. On October 1, 2010, CMS released a State Medicaid Director letter which provided initial guidance to the States regarding the RAC program. CMS issued an educational DVD entitled “Medicaid RACs: Are You Ready?” targeted to State Medicaid and Program Integrity Directors and held a webinar for states offering RAC procurement tips. Additionally, on November 4, 2010, CMS hosted an educational forum describing Lessons Learned from CMS’s experience with Medicare RACs.

A copy of the regulation may be viewed at the Federal Register’s website, http://www.ofr.gov/inspection.aspx. For Additional information on the Affordable Care Act can be accessed at, http://www.healthcare.gov/.

Indiana Performs Well on HCAHPS

2010-11-07T22:12:00.004-05:00

The following is a table of how States performed on the HCAHPS overall rating question from Jan 09 to Dec 09. The table is sorted from high to low based on the percentage of patients responding with a rating of 9 or 10 on this 10 point scale.

As you can see, the average of Indiana hospitals ranks 7th of all states for this question.

% State
73 SD
72 KS
72 LA
72 IA
71 NE
71 ME
71 IN
70 VT
70 ID
70 NH
70 WI
69 CO
69 UT
69 MN
69 NC
68 AL
68 MI
68 OK
68 KY
68 TX
68 SC
67 MO
67 MS
67 MA
67 OH
67 OR
67 TN
66 WA
66 AZ
66 AR
66 GA
65 CT
64 AK
64 WV
64 VA
64 PA
64 IL
64 RI
63 WY
63 MT
63 CA
62 DE
62 NV
62 ND
62 FL
61 MD
61 NM
60 NJ
59 HI
58 NY
58 DC

Indiana Hospitals HCAHPS Performance

2010-11-07T21:13:00.007-05:00

The following is a table of the performance of Indiana hospitals (Jan 09 to Dec 09) on the HCAHPS overall rating question. The table is sorted from high to low based on the percentage of patients providing a response of 9 or 10 on this 10 point scale.

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

Note that the following hospitals were tagged as "Survey results are not available for this reporting period".

WHITE COUNTY MEMORIAL HOSPITAL
UNITY MEDICAL AND SURGICAL HOSPITAL
THE HEART HOSPITAL AT DEACONESS GATEWAY LLC
ST MARY'S WARRICK HOSPITAL INC
PUTNAM COUNTY HOSPITAL
PINNACLE HOSPITAL
PERRY COUNTY MEMORIAL HOSPITAL
KENTUCKIANA MEDICAL CENTER LLC
JASPER COUNTY HOSPITAL
GREENE COUNTY GENERAL HOSPITAL
COMMUNITY HOSPITAL OF BREMEN INC
ADAMS MEMORIAL HOSPITAL

The "Gift"

2010-10-11T22:10:00.006-04:00

This is not exactly "Healthcare Quality", but it is well worth the 3 minutes. It keeps our work in perspective.

(If you don't see the video embedded above, it is being blocked.)