MH&SC HOSPITAL SURVEY RESULTS Michigan Patient Safety Conference March 30, 2006 AkkeNeel Talsma, PhD, RN Clinical a

1. MH&SC HOSPITAL SURVEY RESULTS Michigan Patient Safety Conference March 30, 2006 AkkeNeel Talsma, PhD, RN Clinical and Research Consultant to MH&SC

2. Objectives • Review 2005 MH&SC Hospital Survey background and scoring of survey • Findings and utilization of MH&SC Hospital Survey 2005 • Review trends hospital survey data 2002 - 2005 • Future developments

3. 1. Review 2005 MH&SC Hospital Survey Background, Reporting, and Scoring

4. 1. MH&SC Joint Hospital Survey: Background • MH&SC 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

5. 1. MH&SC Joint Hospital Survey: Background • Goal is to collect data needed by both MH&SC 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 MH&SC to stimulate movement towards best practices in Michigan hospitals in included areas of care • Content has remained nearly identical, allowing for trend analyses

6. 1. MH&SC Joint Hospital Survey: Background • Results are published on MH&SC 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 MH&SC members and results are shared at public meetings

7. 2. MH&SC Joint Hospital Survey: Public Reporting and Utilization Please visit: www.mihealthandsafety.org

8. 1. MH&SC 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

9. 1. MH&SC 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%

10. 1. MH&SC 2005 Survey: Categories Scoring Methodology • Non-volume activities are related to three content areas: • Medical Appropriateness (50%) • Does your hospital’s medical staff have appropriateness criteria for determining the medical necessity of <this procedure>? • Does your hospital require the medical staff to use the appropriateness criteria for clinical case reviews of <this procedure>? • Structure, Process, Outcome Measures (50%) • Does your hospital have a risk-adjustment system for <this procedure>? • Does your hospital collect risk-adjusted mortality data for <this procedure>? • Does your hospital collect risk-adjusted morbidity indicators for <this procedure>? • Does your hospital and/or its <specialty> surgeons willing to submit clinical data related to <this procedure> to a comprehensive statewide data base? • Each guideline is scored separately. The maximum score is 100%

11. 1. MH&SC 2005 Survey: Scoring Methodology Please visit: www.mihealthandsafety.org

12. 1. MH&SC Joint Hospital Survey: Public Reporting and Utilization • MH&SC 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?

13. 2. Findings MH&SC Hospital Survey 2005

14. 2. Findings MH&SC 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

15. Total Number of Hospital Responses: BCBSM Peer Group*: Respond Total N(%) Peer 1:Teaching 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 2. 2005 MH&SC Survey Response Rate: By BCBSM Peer Group

16. 2. 2005 MH&SC 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

17. 2. MH&SC 2005 Survey Response by BCBSM Peer Group and Region

18. 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 Met Volume Met 95% Met 80% ThresholdActivitiesActivities 2. Annual MH&SC Joint Hospital Survey: 2005 Results by Category

19. 2. MH&SC 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 MH&SC consumer report • Use results as a baseline to determine the need for collaborative improvement efforts in this area

20. 2. MH&SC 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

21. 2. MH&SC Joint Hospital Survey: RCA and HFMEA • Health Failure Mode Effects Analysis (HFMEA) • HFMEA’s (“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

22. 2. MH&SC Joint Hospital Survey: RCA and HFMEA • 99 of 100 hospitals (99%) responded to survey questions • RCA is often conducted (n=88), regularly exceeding the minimum JCAHO requirements • Sentinel event: n=79 conduct RCA • Adverse event: n=69 conduct RCA • Improvement plan follows RCA (n=94) • Improvement plan also evaluated (n=81) • Small variations in response by peer group

23. 2. MH&SC 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 HFMEA’s a year. • If a HFMEA is conducted, it is nearly always followed by a risk-reduction activity (n=89/98, 91%) • The HFMEA related risk-reduction activity is typically evaluated (n=79/89, 89%)

24. 2. Distribution conducting RCA / HFMEA by peer group

25. 3. MH&SC Joint Hospital Survey: 2002-2005 Trends

26. 3. MH&SC Survey Response Rate: 2002-2005 Trend

27. 3. Annual MH&SC 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

28. 3. Annual MH&SC 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

29. 3. MH&SC Survey Multi-year Response Rates * Please refer to The Leapfrog Group Definition in Appendix III

30. 3. Annual MH&SC Joint Hospital Survey: Trended Results by Category

31. 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)

32. 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)

33. 3. Annual MH&SC Joint Hospital Survey: Trended Results by Category

34. 3. MH&SC Survey Scoring: 2002-2005 Trend Hospitals that met the minimum procedure volume and recommended activities

35. 3. Comparison MH&SC 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 MH&SC 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

36. 4. Future Developments

37. 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

38. 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

39. 4. Future Developments • Reconvene MH&SC 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 MH&SC Survey Roll-out schedule (likely launch date Monday, August 28, 2006) • Bring recommendations back to MH&SC

40. APPENDICES

41. I. MH&SC 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)

42. 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) Detroit Receiving Hospital & University Health Center (4 yrs) Dickinson County Healthcare System (4 yrs) Eaton Rapids Medical Center (4 yrs) Foote Health System (4 yrs) Garden City Hospital (4 yrs) Genesys Health System (4 yrs) 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) Marlette Community Hospital (4 yrs) Memorial Medical Center of West Michigan (4 yrs) Mercy General Health Partners – Oak Avenue Campus (3 yrs) Mercy General Health Partners-Sherman Blvd. Campus (3 yrs) Mercy Hospital (3 yrs) Mercy Hospital Cadillac (4 yrs) Mercy Hospital Grayling (4 yrs) II. List of Participating Hospitals in 2005 Survey (n=100) (Yrs Survey participation)

43. 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) Portage Health System (4 yrs) Providence Hospital & Medical Centers (4 yrs) Saint Joseph Mercy Hospital (4 yrs) Saint Joseph Mercy Livingston (McPherson) Hospital (4 yrs) Saint Joseph Mercy Saline Hospital (4 yrs) Saint Mary’s 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. Joseph’s Healthcare (1 yr) St. Mary Mercy Hospital (4 yrs) St. Mary’s of Michigan (1 yr) Sturgis Hospital (4 yrs) University of Michigan Hospitals & Health Centers (4 yrs) West Branch Regional Medical Center (3 yrs) West Shore Medical Center (3 yrs) William Beaumont Hospital (4 yrs) Zeeland Community Hospital (4 yrs) II. List of Participating Hospitals in 2005 Survey (n=100) (Yrs Survey participation) (cont’d.)

44. III. Leapfrog Group Definition of Urban and Rural Hospitals • Leapfrog has relied on Medicare’s 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 Medicare’s 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