Top Ten Health Systems
The Change Agents for Quality
JEAN CHENOWETH
SR. VICE PRESIDENT, PERFORMANCE IMPROVEMENT
& 100 TOP HOSPITALS PROGRAMS
THOMSON REUTERS
RAISING THE BAR
2009 100 TOP HOSPITALS STUDY
2
2004 – 2008
100 TOP HOSPITALS:® NATIONAL BENCHMARKS
2008
 A National Balanced Scorecard



Ten measures of current performance achievement
Nine equally weighted measures
Seven equally weighted measured trended over 5 years
 17 Year Effort To Guide Improvement




Modified balanced scorecard theory – Norton and Kaplan, Harvard University
Validation of hospital balanced scorecard – Griffith and Alexander, U of M
Objective statistical analysis of public data
Peer-reviewed methodologies
2009 NATIONAL BENCHMARKS STUDY
FIVE CLASSES FOR VALID BENCHMARKS
ADJUSTMENT FOR FACILITY-LEVEL DATA
Winners
Total #
Hosps
15
173
25
423
Large Community Hospitals – 250+ beds; NOT teaching
20
338
Medium Community Hospitals – 100 to 249 beds; NOT teaching
20
1028
20
100
964
2,926
Hospital Classes - The Comparison Groups
Major Teaching Hospitals – three ways to qualify:
400+ beds plus 0.25 IR/bed ratio and
- 10 GME sponsored programs OR
- 20 GME programs total
30 GME programs total (regardless of beds or IR/bed ratios)
0.60 IR/Bed ratio (regardless of beds or GME count)
Teaching Hospitals – 200+ beds and
- 0.03 IR/bed ratio OR
- 3 GME programs total
Small Community Hospitals – 25 to 99 beds; NOT teaching
2009 National In-Study Hospital Totals
4
100 TOP NATIONAL BALANCED SCORECARD
FIVE DOMAINS – TEN MEASURES
QUALITY
• Risk-Adjusted Mortality Index
• Risk-Adjusted Complications Index
• Patient Safety Index
• Core Measures Mean Percent
WEIGHT
1
1
1
1
EXTENDED OUTCOMES
• 30 Day Mortality Rate
• 30 Day Readmission Rate
½
½
EFFICIENCY
• Severity-Adjusted Average Length of Stay
• Expense per Adjusted Discharge – Wage, Case-Mix Adjusted
1
1
FINANCIAL STABILITY
• Adjusted Operating Profit Margin (%)
1
PATIENT PERCEPTION OF CARE
• HCAHPS Score (Patients' Overall Hospital Rating)
1
Note: Trend data for HCAHPS & 30 Day Mortality & Readmit rates not available
2009 100 TOP HOSPITALS TRANSFORMATION
 Transformation of 100 Top Hospitals®: National Balanced Scorecard




Two-dimensional matrix shows leadership impact on performance over time
Results of improvement efforts relative to national peer benchmarks
Validated by academics
Public data and peer-reviewed methodologies
 Scalable information provides view of relative performance against
peers and national benchmarks





Hospitals
Health systems
Markets
States, regions
Insurance networks
 Tracks journey to excellence
 Actionable by leadership at high level in health systems and
hospitals
REGIONAL SHIFTS IN STATE PERFORMANCE
2004 – 2009 100 TOP HOSPITALS BALANCED SCORECARD
2004
2009
2006
100 Top Hospital Performance
2005 State Level Rankings
2003 – 2008 DATA YRS.
Quintile 1-Best
Quintile 2
Quintile 3
Quintile 4
Quintile 5-Worst
(10)
(10)
(10)
(10)
(11)
REGIONAL VARIATION IS SIGNIFICANT
MIDWEST
SOUTH
MIDWEST
Iowa
Michigan
Minnesota
Nebraska
N Dakota
Ohio
S. Dakota
Wisconsin
Illinois
Indiana
Missouri
Kansas
2005
2
2
1
2
1
1
1
1
3
2
2
2
2006
2
1
2
3
1
1
1
1
2
1
3
4
2007
1
1
2
2
1
1
1
1
2
2
3
2
2008
1
1
1
1
1
1
1
1
2
2
2
3
2009
1
1
1
2
1
1
1
1
2
2
2
3
SOUTH
Delaware
Kentucky
Maryland
Oklahoma
Tennessee
Texas
2005
4
1
2
4
2
4
2006
5
1
3
4
2
4
2007
3
1
3
3
2
3
2008
2
2
3
3
3
3
2009
1
3
4
4
2
3
Alabama
Arkansas
Florida
Georgia
Mississippi
N Carolina
Virginia
DC
Louisiana
S Carolina
W Virginia
3
5
3
3
5
3
4
4
4
5
4
3
4
3
3
4
3
4
5
4
5
3
4
3
4
4
4
4
5
4
5
4
4
4
4
4
4
4
5
5
5
3
5
4
3
4
4
4
5
4
4
5
4
5
5
WEST
Montana
Utah
Arizona
Colorado
Idaho
Washington
Oregon
California
Wyoming
Alaska
Hawaii
Nevada
New Mexico
8
2005
3
1
1
1
4
1
1
4
5
5
5
5
3
2006
2
2
2
2
2
1
3
4
5
5
5
5
5
2007
1
1
2
2
1
2
3
5
5
5
5
5
5
2008
1
1
2
2
2
2
3
4
4
5
5
5
5
2009
1
1
2
2
1
2
3
4
5
5
5
5
5
NORTHEAST
Massachusetts
Connecticut
Maine
New Hampshire
Pennsylvania
Vermont
New Jersey
New York
2005
2
3
4
3
2
3
5
5
2006
1
1
3
2
3
4
5
5
2007
2
3
4
4
3
4
5
5
2008
2
3
3
3
3
4
5
5
2009
2
3
3
2
3
3
5
5
Rhode Island
4
4
5
5
4
WEST
NORTHEAST
MAGNITUDE: NATIONAL PERFORMANCE VARIANCE
LIKELIHOOD OF CARE IN BALANCED, HIGH PERFORMING HOSPITALS
100
IMPROVING
ND
NH
SC
OK
WI
AR
NJ
ID
KS
TX
UT
MS
60
MI
NV
MA
NY
PA
TN
IN
MD
WA
GA
HI
40
WV
NE
OH
VA
LA
IL
CA
MT
CT
OR
DECLINING
RI
DC
0
0
20
MN
ME
AL
FL
NM
20
Top
10%
IA
KY
NC
80
SD
LEADING
WY
VT
2003 - 2007 Rate of Improvement
Top 10%
DE
AK
40
MO
CO
AZ
AT RISK
60
2007 Level of Achievement
Source: Thomson Reuters 100 Top Database 2008
9
80
100
MARKET VARIATIONS RAISE LEADERSHIP ISSUES
5
2009 100 Top Hospitals Quintiles
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
1
5
5
1
5
1
5
5
1
5
1
5
5
1
3
1
5
3
1
5
2
1
2
1
2
4
5
1
3
5
4
5
4
5
4
5
3
4
5
3
4
5
3
4
5
2
3
4
5
2
3
4
5
4
5
3
1
2
3
4
5
1
2
3
4
5
1
2
3
5
5
5
3
3
5
3
2
2
5
4
1
1
1
5
4
4
1
1
4
1
2
3
4
5
Minneapolis CBSA
Atlanta CBSA
NYC CBSA
23 Hospitals
30 Hospitals
58 Hospitals
Lowest quintile (1) is best performance
Highest quintile (5) is worst performance
ATLANTA MARKET
MOVING TOWARD HIGHER PERFORMANCE AND STRONGER INDUSTRY
5
2009
Relative Performance
Hospital Count = 30
2008
Relative Performance
Hospital Count = 32
2
5
2
5
2
5
3
5
3
5
2
5
1
3
5
2
5
1
3
5
2
3
4
5
1
2
3
4
5
2
3
4
5
1
2
3
4
5
2
3
4
5
1
2
3
4
5
2
3
4
5
1
2
3
4
5
2
3
4
5
Lowest quintile (1) is best performance
Highest quintile (5)11
is worst performance.
1
QUESTIONS
 Should health systems be accountable for quality of care?
 Are health systems measuring performance across the
communities served?
 Board quality and safety
87.7% *
 Board community benefit plan w measures
34.2%
 Board community benefit priorities, no plan
41.2%
 Should health system performance be transparent?
*
Prybil, L., Governance in Not for Profit Community Health Systems,2009
Page 12
HEALTH SYSTEMS ARE IN DRIVER’S SEAT
 Review of performance shifts over 17 years
 Performance shifts regionally and in reaction to a major environmental
change
 Highest performance is being driven in states with active collaboratives
 Hospitals in states with high levels of competition tend to have weak
state collaboratives. Strong preference for “member only” collaboration
 Health systems are positioned to be the drivers of
improvement during reform
 Health system boards and executives have power to
– Lead and align
• Determine mission
• Set standards and targets
• Set incentives
• Take corrective action
Page 13
INTRODUCING 100 TOP HOSPITALS: HEALTH
SYSTEMS QUALITY/EFFICIENCY MEASUREMENT
 Definition of health system
 Minimum of two acute care general hospitals
 Corporate office and hospital financial relationship
– 2007 Cost report shows related organization financial transactions
– 2007 Cost report shows home office entries
 All systems included, regardless of size
 Measures reflect aggregated data across the whole system,
including CAHs
 Measures adjusted to be meaningful at system level
 100 Top Hospitals® Health Systems Quality/Efficiency Award
 10 Winners out of 252 Health Systems
 Represent top 2.5% of health systems
14
14
BENEFITS FOR HEALTH SYSTEM LEADERSHIP
 Boards and executives of health systems see and evaluate






Level of quality provided by health system as an organization
Answers “How good are we as a sum of our parts?”
Effectiveness of performance incentives to drive systemic excellence
Relative value provided to communities and public
Relative level of quality provided by system name or brand
Actionable leadership information at system and hospital levels
 Better information, better basis for action
 Enhanced decision making
 Objective basis for mission and goal adjustment
 Objective basis for reporting progress and value to internal and
external stakeholders
15
THE TOP TEN HEALTH SYSTEMS
ADVOCATE HEALTH CARE
CATHOLIC HEALTH PARTNERS
HEALTH ALLIANCE OF GREATER CINCINNATI
HEALTHEAST CARE SYSTEM
HENRY FORD HEALTH SYSTEM
KETTERING HEALTH NETWORK
OHIOHEALTH
PRIME HEALTHCARE SERVICES
TRINITY HEALTH
UNIVERSITY HOSPITALS HEALTH SYSTEM
16
BROADENING ACCOUNTABILITY
TRINITY HEALTH SYSTEM SCORES
100 TOP HOSPITALS: HEALTH SYSTEM QUALITY/EFFICIENCY BENCHMARKS SCORECARD
HEALTH SYSTEM
NAT. HEALTH SYSTEM
BENCHMARKS,
IN PERCENTILES
TRINITY HEALTH
SYSTEM
IN PERCENTILES
OVERALL
QUINTILE
MORT
QUINTILE
COMP
QUINTILE
PSI
QUINTILE
CORE MEAS
QUINTILE
ALOS
QUINTILE
97.8
94.3
90.8
83.8
88.1
86.6
96.4
71.0
96.8
49.8
90.5
84.7
QUINTILE PERFORMANCE KEY
QUINTILE
PERCENTILE RANGE
> 80 TO 100
PERFORMANCE
BEST
> 60 TO 80
> 40 TO 60
> 20 TO 40
> 0 TO 20
WORST
STRONG ALIGNMENT OF PERFORMANCE
Measuring the Journey of System Members With 100 Top Hospitals®: National Benchmark Matrix
CALIFORNIA – LARGE COMMUNITY
INDIANA – SMALL COMMUNITY
IOWA – MEDIUM COMMUNITY
TENNESSEE – TEACHING COMMUNITY
18
WEAK ALIGNMENT OF PERFORMANCE
Measuring the Journey of System Members With 100 Top Hospitals®: National Benchmark Matrix
MICHIGAN – TEACHING COMMUNITY
OHIO – SMALL COMMUNITY
MICHIGAN – MEDIUM COMMUNITY
OHIO – TEACHING
19
TOP QUINTILE VS. LOWEST QUINTILE
PERFORMANCE VARIES WIDELY ON QUALITY AND EFFICIENCY
PERFORMANCE MEASURE



BEST
QUINTILE
WORST
QUINTILE
DIFFERENCE
BETWEEN BEST
AND WORST
PERCENT BY WHICH BEST
QUINTILE OUTPERFORMS
WORST QUINTILE
Mortality Index
0.85
1.14
-0.29
25.4%
Complications Index
0.87
1.08
-0.21
19.0%
Core Measures
90.7%
87.0%
3.7%
---
PSI Index
0.95
1.08
-0.14
12.7%
LOS Index
0.92
1.09
-0.17
15.8%
Results suggest that health systems can play major role in transformation
Health system leadership could be powerful catalyst for driving rapid industry
improvement
All differences are significant
20
TOP TEN HEALTH SYSTEMS
PATIENT
CORE
MORTALITY COMPLICATION
SAFETY
MEASURES
ALOS
PERCENTILE
PERCENTILE PERCENTILE PERCENTILE PERCENTILE
SYSTEM NAME
OVERALL
QUINTILE
Kettering Health Network
1
97.6
99.2
90.1
98.4
96.0
Prime Healthcare Services
1
94.8
87.7
73.0
98.0
99.6
Health Alliance of Cincinnati
University Hospitals Health
System
1
98.4
89.1
91.3
76.2
92.5
1
86.1
89.1
90.9
78.6
88.5
Advocate Health Care
1
96.8
99.6
48.6
95.6
77.4
Catholic Healthcare Partners
1
97.2
98.8
90.5
66.7
63.9
Henry Ford Health System
1
93.7
92.5
68.7
85.7
62.1
HealthEast Care System
1
49.2
87.3
96.4
77.0
92.1
Trinity Health
1
1
71.0
96.8
49.8
90.5
84.7
52.4
84.7
77.4
92.9
79.0
OhioHealth
Page 21
BOTTOM TEN HEALTH SYSTEMS
SYSTEM STATE
OVERALL
MORT
COMP
PSI
CORE MEAS
ALOS
PERCENTILE PERCENTILE PERCENTILE PERCENTILE PERCENTILE PERCENTILE
ALABAMA
5
21.6
24.6
17.5
29.4
29.0
NEW YORK – LONG ISLAND
5
3.2
15.9
15.9
84.7
1.2
CALIFORNIA
5
7.9
45.2
7.5
31.9
25.0
GEORGIA
5
4.4
13.9
27.4
19.6
46.0
NEW YORK - UPSTATE
5
26.8
29.0
4.4
39.7
8.7
WEST VIRGINIA
5
5.6
26.8
26.2
34.7
14.7
HAWAII
5
9.7
46.4
31.3
14.7
0.4
NEVADA
5
2.4
41.5
2.0
10.9
44.4
NEW YORK CITY
5
36.1
2.8
20.4
27.4
5.6
NEW YORK – WEST CHESTER
5
16.3
21.0
6.0
33.9
1.6
Page 22
WHAT WE KNOW TO DATE
 TOP 10
 Geographic Region
 9 Midwest OH, MI, MN, IL
 1 West
CA
 Religious Affiliation
 4 Religious
 6 Secular
 Ownership
 1 For Profit
 9 Not for Profit
 BOTTOM 10
 Geographic Region
 4 North East
 3 South
 3 West
NY
AL, GA, WV
CA, HI, NV
 Religious Affiliation
 2 Religious
 8 Secular
 Ownership
 10 Not for Profit
– 2 Govt
– 1 Govt
SOURCE - AHA GUIDE ISSUE, 2010
Page 23
WHAT WE KNOW TO DATE
 BOTTOM 10 Centralization
 TOP 10 Centralization
 3 Centralized
 5 Centralized
 1 Centralized, Phys/Insurance
 0 Centralized, Phys/Insurance
 4 Moderately Centralized
 3 Moderately Centralized
 1 Decentralized
 0 Decentralized
 1 Independent
 2 Independent
 Size
 Size
 Range: 3 – 42 hospitals
 Range: 2 – 19 hospitals
 Average: 13 hospitals
 Average: 7 hospitals
SOURCE - AHA GUIDE ISSUE, 2010
Page 24
WHAT WE KNOW TO DATE
 Top 10
 Quality was part of mission for years
 Use of balanced scorecard
 EMR
 CPOE
 Outsiders on Board
Page 25
TRANSPARENCY AT THE HEALTH SYSTEM LEVEL
 Challenge for health care leaders
 Measures achievement of mission
 Basis for assessing meaning of system brand
 Provides intelligence for better business decisions
 Raises level of accountability
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