Michigan Health and Safety Coalition

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MHSC HOSPITAL SURVEY RESULTS Michigan Patient
Safety Conference March 30, 2006 AkkeNeel
Talsma, PhD, RN Clinical and Research Consultant
to MHSC
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Objectives

• Review 2005 MHSC Hospital Survey background and
  scoring of survey
• Findings and utilization of MHSC Hospital Survey
  2005
• Review trends hospital survey data 2002 - 2005
• Future developments

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• 1. Review 2005 MHSC Hospital Survey Background,
  Reporting, and Scoring

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1. MHSC Joint Hospital Survey Background

• MHSC survey conducted since 2002 jointly with
  The Leapfrog Group since 2003
• Survey items developed with multi-disciplinary
  support from hospitals and physicians throughout
  the state
• Clinical experts convened workgroup to review
  existing evidence, establish current best
  practice
• Survey items were developed based on group
  consensus and sign-off by Oversight workgroup

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1. MHSC Joint Hospital Survey Background

• Goal is to collect data needed by both MHSC and
  The Leapfrog Group using a single survey tool
• reduces data collection burden on hospitals and
  health plans
• allows Leapfrog to provide comparative data to
  national purchasers
• allows MHSC to stimulate movement towards best
  practices in Michigan hospitals in included areas
  of care
• Content has remained nearly identical, allowing
  for trend analyses

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1. MHSC Joint Hospital Survey Background

• Results are published on MHSC website for
  consumers (www.mihealthandsafety.org)
• Hospitals that submit the survey receive a CD
  with their summary results
• Results are shared with Michigan health plans to
  assist with contract decisions
• Presentation to MHSC members and results are
  shared at public meetings

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2. MHSC Joint Hospital Survey Public Reporting
and Utilization
Please visit www.mihealthandsafety.org
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1. MHSC 2005 Survey Categories Scoring
Methodology

• Volume thresholds that reflect recent
  evidence-based literature and clinical expert
  opinion
• Open Heart Surgery Recommended Minimum Annual
  Volume 200
• Percutaneous Coronary Intervention Annual Volume
  400
• Abdominal Aortic Aneurysm Annual Volume 20
• Carotid Endarterectomy Annual Volume 50
• Esophagectomy Annual Volume 7
• Low Birthweight Infants Annual Volume 70
• Two aspects measured in survey
• Volume reported but not scored
• Non-volume activities reported and summary score

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1. MHSC 2005 Survey Categories Scoring
Methodology

• Structure, process and outcome characteristics
  related to quality of care and patient safety
• Two aspects
• Volume (not scored)
• Non-volume activities (scored)
• Volume aspect is presented as a raw value
  compared to the threshold volume
• Non-volume activities are related to three
  content areas
• medical appropriateness (50)
• risk-adjustment (25) and
• participation (or willingness to participate) in
  a statewide database (25)
• Each guideline is scored separately maximum
  score is 100

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1. MHSC 2005 Survey Categories Scoring
Methodology

• Non-volume activities are related to three
  content areas
• Medical Appropriateness (50)
• Does your hospitals medical staff have
  appropriateness criteria for determining the
  medical necessity of ltthis proceduregt?
• Does your hospital require the medical staff to
  use the appropriateness criteria for clinical
  case reviews of ltthis proceduregt?
• Structure, Process, Outcome Measures (50)
• Does your hospital have a risk-adjustment system
  for ltthis proceduregt?
• Does your hospital collect risk-adjusted
  mortality data for ltthis proceduregt?
• Does your hospital collect risk-adjusted
  morbidity indicators for ltthis proceduregt?
• Does your hospital and/or its ltspecialtygt
  surgeons willing to submit clinical data related
  to ltthis proceduregt to a comprehensive statewide
  data base?
• Each guideline is scored separately. The maximum
  score is 100

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1. MHSC 2005 Survey Scoring Methodology
Please visit www.mihealthandsafety.org
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1. MHSC Joint Hospital Survey Public Reporting
and Utilization

• MHSC Hospital Survey results available to
• Consumers www.mihealthandsafety.org
• Health plans and insurers receive summarized
  information
• Hospitals receive survey summary and
  benchmarking detail
• Public meetings present current survey results
  and trends throughout the state
• Future publication?

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• 2. Findings MHSC Hospital Survey 2005

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2. Findings MHSC Hospital Survey 2005

• Results are evaluated by
• Peer group, see Appendix I for definitions
• MHA region
• Health system
• Meeting minimum procedure patient volumes
• Meeting 80 of recommended activities (4 bullets)
• Consistency of submissions

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2. 2005 MHSC Survey Response Rate By BCBSM Peer
Group

• Total Number of Hospital Responses
• BCBSM Peer Group Respond Total N()
• Peer 1Teaching Hospital 27 (27) 28
  (96)
• Peer 2 Large Urban Hospital 13 (13) 21
  (62)
• Peer 3 Small Urban Hospital 18 (18) 22
  (56)
• Peer 4 Rural Hospital 11 (11)
  22 (50)
• Peer 5 Small Rural Hospital 31 (31) 43
  (72)
• Other 0
  (0) 2 (0)
• Total 100 138 (72.5)
• Definition of Peer group available in Appendix I

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2. 2005 MHSC Survey Response Rate Distribution
by Region
Hospitals/
Hospital Region Region
Responses () Southeast 41 (30)
37 (90) Southwest 14 (10) 8
(57) West Central 26 (19) 20
(77) Mid Michigan 10 (7) 5
(50) East Central 20 (15) 15
(75) North Central 12 (9) 8
(67) Upper Peninsula 15 (11) 7 (47)
Total 138 (100) 100 (72.5) List of
participating hospitals is available in Appendix
II
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2. MHSC 2005 Survey Response by BCBSM Peer Group
and Region
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2. Annual MHSC Joint Hospital Survey 2005
Results by Category

• Met Volume Met 95 Met 80
• Threshold Activities Activities

• Guideline
• Open Heart (200) N 23/29 (79.3) 21 (72.4) 22
  (75.9)
• PCI (400) N 24/27 (88.9) 18 (66.7) 22
  (81.5)
• AAA (20) N 33/52 (63.5) 23 (44.2) 29
  (55.8)
• Carot. Endart (50) N 36/57 (63.2) 27
  (47.4) 35 (61.4)
• Esophagectomy (7) N 9/31 (29.0)
  2/34 (5.9) 17/34 (50)
• LBW Infants (70) N 11/22 (50.0) 11 (50.0) 15
  (68.2)
• Cong. Anom. (70) N 11/22 (50.0) 8 (36.4) 18
  (81.8)
• ICU Physician NA 20 (25.0) 29 (36.3)
• Staffing

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2. MHSC Joint Hospital Survey RCA and HFMEA

• Patient Safety Tools
• Root Cause Analysis (RCA)
• Healthcare Failure Mode Effect Analysis (HFMEA)
• This section is NOT scored nor are results posted
  on the MHSC consumer report
• Use results as a baseline to determine the need
  for collaborative improvement efforts in this area

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2. MHSC Joint Hospital Survey RCA and HFMEA

• Root Cause Analysis (RCA)
• Root-case analysis is a retrospective qualitative
  process aimed at uncovering the underlying
  cause(s) of an error by looking at the sharp
  end of an error to the enabling latent
  conditions that contributed to or enabled the
  occurrence of the error
• A RCA focuses primarily on systems and processes,
  not individual performance. The result is an
  action plan that identifies the strategies that
  the organization intends to implement to reduce
  the risk of similar events occurring in the future

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2. MHSC Joint Hospital Survey RCA and HFMEA

• Health Failure Mode Effects Analysis (HFMEA)
• HFMEAs (FMEA) goal is to prevent errors from
  occurring by attempting to identify all of the
  ways a device or process can fail, estimate the
  probability and consequence of each failure, and
  then take action to prevent the potential
  failures from occurring
• HFMEA is typically conducted by multidisciplinary
  teams in an HCO on many different patient care
  processes, including device design

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2. MHSC Joint Hospital Survey RCA and HFMEA

• 99 of 100 hospitals (99) responded to survey
  questions
• RCA is often conducted (n88), regularly
  exceeding the minimum JCAHO requirements
• Sentinel event n79 conduct RCA
• Adverse event n69 conduct RCA
• Improvement plan follows RCA (n94)
• Improvement plan also evaluated (n81)
• Small variations in response by peer group

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2. MHSC Joint Hospital Survey RCA and HFMEA

• 98 of 100 (98) hospitals indicated conducting
  HFMEA
• 20/98 (20) hospitals conduct HFMEA more than 5
  times a year
• The majority of hospitals (68/98, 69) conduct
  between 1 3 HFMEAs a year.
• If a HFMEA is conducted, it is nearly always
  followed by a risk-reduction activity (n89/98,
  91)
• The HFMEA related risk-reduction activity is
  typically evaluated (n79/89, 89)

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2. Distribution conducting RCA / HFMEA by peer
group
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3. MHSC Joint Hospital Survey 2002-2005 Trends
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3. MHSC Survey Response Rate 2002-2005 Trend

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3. Annual MHSC Joint Hospital Survey 2002 -
2005 Trends

• Nearly half (47) of all hospitals submitted the
  survey all 4 years
• Over a third (34) of all hospitals submitted a
  survey at least once

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3. Annual MHSC Joint Hospital Survey 2002 -
2005 Trends

• Peer 1 hospitals were most likely to submit a
  survey all years (69 of all peer 1 hospitals)
• Almost half of peer 2 (46) and peer 3 (48)
  hospitals submitted a survey for all years
• Over half (55) of Peer 5 hospitals and only 24
  of peer 4 hospitals participated in all survey
  years

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3. MHSC Survey Multi-year Response Rates
Please refer to The Leapfrog Group Definition
in Appendix III
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3. Annual MHSC Joint Hospital Survey Trended
Results by Category
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3. Correlation between volume and meeting
recommended activities

• Correlation between NICU volume and meeting
  recommended activities
• Low birth weight infants (r -.01, p.94, n.s.)
• Infants with congenital anomalies (r -.06, p.56,
  n.s.)
• Correlation between ICU physician staffing and
  meeting recommended activities
• Low birth weight infants (r .42, p.000)
• Infants with congenital anomalies (r .46, p.000)

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3. Correlation between volume and meeting
recommended activities

• Procedures with moderate correlation between
  volumes met and recommended activities
• Open heart surgery (r .46, p.000)
• PCI (r .31, p.001)
• AAA (r .42, p.000)
• CEA (r .32, p.000)
• Esophagectomy (r .30, p.001)

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3. Annual MHSC Joint Hospital Survey Trended
Results by Category
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3. MHSC Survey Scoring 2002-2005 Trend
Hospitals that met the minimum procedure
volume and recommended activities
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3. Comparison MHSC Hospital Survey and The
Leapfrog Group Data

• Based on Leapfrog Group data
• Michigan higher on average in all areas except
  PCI
• (2.8 less in Michigan than nationally)
• Based on MHSC data
• While good progress was made by hospitals in
  implementing guidelines in 2002-2003, performance
  has since stabilized.
• Relatively good performance for Open Heart and PCI

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• 4. Future Developments

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4. Future Developments

• Work with providers, hospitals, insurers, others
  to share results and identify improvement
  opportunities
• Encourage non-participating hospitals to
  participate in the survey
• Implement process improvements by hospitals to
  achieve improved performance scores on the
  activities portion of the survey
• Place survey data on Web site

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4. Future Developments

• Broad involvement and review of data
• Michigan health plans
• Hospital-based organizations and physicians
  performing surveyed procedures
• Public presentations, pertinent publications
• Web-site improvement, incl. search functionality
• Identify pertinent procedures for small and rural
  hospitals
• Validate submitted volumes

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4. Future Developments

• Reconvene MHSC Oversight Group to provide more
  explicit direction and prioritize issue areas for
  implementation groups
• Balance degree of difficulty
• Consumer interests
• Potential impact on quality of care
• Determine 2006 MHSC Survey Roll-out schedule
  (likely launch date Monday, August 28, 2006)
• Bring recommendations back to MHSC

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APPENDICES
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I. MHSC Hospital Survey BCSM Peer Groups

• Peer Group 1 Hospitals with large teaching
  programs
• - 325 or more licensed beds
• Peer Groups 2 4 Other acute care hospitals
• - Peer Group 2 - 325 or more licensed beds
• - Peer Group 3 Meet one of the following two
  groups of criteria
• Non-rural hospital - less than 325 licensed beds
• Rural hospital - more than 150 licensed beds
• - Peer Group 4 - Rural hospital - 150 or less
  licensed beds
• Peer Group 5 Rural hospital - 100 or less
  licensed beds
• Total annual admissions of less than 2,000
• ( Total acute care, psychiatric and
  rehabilitation admissions)

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II. List of Participating Hospitals in 2005
Survey (n100) (Yrs Survey participation)

• Allegan General Hospital (4 yrs)
• Alpena General Hospital (4 yrs)
• Baraga County Memorial Hospital (4 yrs)
• Battle Creek Health System (4 yrs)
• Bon Secours Cottage Health Services-
• Cottage Hospital Campus (4 yrs)
• Borgess - Lee Memorial Hospital (3 yrs)
• Borgess Medical Center (4 yrs)
• Botsford General Hospital (4 yrs)
• Bronson Healthcare Group Inc. (4 yrs)
• Caro Community Hospital (1 yr)
• Carson City Hospital (4 yrs)
• Charlevoix Area Hospital (1 yr)
• Chelsea Community Hospital (3 yrs)
• Children's Hospital of Michigan (4 yrs)
• Clinton Memorial Hospital (2 yrs)
• Covenant Medical Center (4 yrs)
• Crittenton Hospital Medical Center (4 yrs)
• Deckerville Community Hospital (1 yr)

• Grand View Health System (4 yrs)
• Gratiot Community Hospital (4 yrs)
• Hackley Hospital (4 yrs)
• Hackley Lakeshore Hospital (2 yrs)
• Harbor Beach Community Hospital (4 yrs)
• Harper-Hutzel Hospital (4 yrs)
• Healthsource Saginaw (1 yr)
• Helen Newberrry Joy Hospital (3 yrs)
• Henry Ford Bi-County Hospital (1 yr)
• Henry Ford Hospital (4 yrs)
• Henry Ford Wyandotte Hospital (4 yrs)
• Holland Community Hospital (2 yrs)
• Hurley Medical Center (4 yrs)
• Huron Valley-Sinai Hospital (4 yrs)
• Ionia County Memorial Hospital Corporation (2
  yrs)
• Lakeland Regional Health System (4 yrs)
• LakeView Community Hospital (1 yr)
• Lenawee Health Alliance Bixby Campus (2 yrs)
• Lenawee Health Alliance Herrick Campus (2 yrs)

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II. List of Participating Hospitals in 2005
Survey (n100) (Yrs Survey participation)
(contd.)

• Mercy Memorial Hospital Corporation (4 yrs)
• Metropolitan Hospital (4 yrs)
• MidMichigan Medical Center-Clare (4 yrs)
• MidMichigan Medical Center-Gladwin (4 yrs)
• MidMichigan Medical Center-Midland (4 yrs)
• Mt. Clemens Hospital (3 yrs)
• Munising Memorial Hospital (1 yr)
• Munson Medical Center (4 yrs)
• North Oakland Medical Centers (3 yrs)
• North Ottawa Community Hospital (2 yrs)
• Northern Michigan Hospital (4 yrs)
• O.S.F. St. Francis Hospital (2 yrs)
• Oakwood Annapolis Hospital (4 yrs)
• Oakwood Heritage Hospital (4 yrs)
• Oakwood Hospital and Medical Center (4 yrs)
• Oakwood Southshore Medical Center (4 yrs)
• Paul Oliver Memorial Hospital (3 yrs)
• POH Medical Center (4 yrs)
• Port Huron Hospital (4 yrs)

• Saint Marys Health Care (4 yrs)
• Saint Mary's of Michigan Standish Hospital (3
  yrs)
• Scheurer Hospital (4 yrs)
• Sinai-Grace Hospital (4 yrs)
• Sparrow Hospital Health System (4 yrs)
• Spectrum Health-Blodgett Campus (4 yrs)
• Spectrum Health Butterworth Campus (3 yrs)
• Spectrum Health United Memorial Kelsey Campus
  (1 yr)
• Spectrum Health United Memorial United Campus
  (2 yrs)
• Spectrum Health-Reed City Campus (3 yrs)
• St. John Detroit Riverview Hospital (4 yrs)
• St. John Hospital Medical Center (4 yrs)
• St. John Macomb Hospital (2 yrs)
• St. John Oakland Hospital (4 yrs)
• St. John River District Hospital (3 yrs)
• St. Joseph Health System Tawas (3 yrs)
• St. Joseph Mercy Oakland (4 yrs)
• St. Josephs Healthcare (1 yr)
• St. Mary Mercy Hospital (4 yrs)

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III. Leapfrog Group Definition of Urban and Rural
Hospitals

• Leapfrog has relied on Medicares inpatient
  prospective payment system (IPPS) to distinguish
  between urban and rural areas
• Medicare designates a hospital based on the
  county in which the hospital is located. It has
  used metropolitan areas to classify counties as
  urban or rural
• Leapfrog has followed Medicares approach for
  urban hospitals if it is located in a county that
  is
• Part of a Metropolitan Statistical Area (MSA), or
• Part of a Consolidated Statistical Area (CSA) if
  it includes at least one MSA