Wisconsin Hospitals Raise the Quality Bar—Across the Board

Reducing readmissions remains one of the most difficult challenges for hospitals everywhere. Members of the Wisconsin Hospital Association (WHA), however, have been working together to reduce the incidence of hospital readmissions within 30 days of discharge—and their performance runs far ahead of the national average.

Hospitals across the state continue to work on reducing readmissions through participation in the WHA Partners for Patients project. As part of the AHA Partners for Patients project, it focuses on reducing hospital readmissions by 20% and hospital-acquired harm by 40%.

Readmissions constitute one of the largest opportunities to drive unnecessary cost out of the health-care system. An average readmission costs $9,600, according to the WHA’s 2013 Quality Report,1 and WHA member hospitals have reduced readmissions by 22%, exceeding the CMS goal of 20%. This work has eliminated readmissions for an estimated 3,556 patients and reduced health-care spending by $34.1 million. Together, the WHA’s member hospitals report a savings of almost $46 million from quality improvement in less than two years.

WHA Hit List

The WHA’s Partners for Patients program started in January 2012, according to Kelly Court, the WHA’s chief quality officer. The areas of patient harm on which the WHA project is most focused include:

• central-line infections,

• catheter-associated urinary-tract infections,

• surgical-site infections,

• venous thromboembolism,

• falls,

• pressure ulcers,

• adverse drug events, and

• early elective deliveries.

The WHA measures both quality of performance and cost impact for each of those areas. The report indicates notable improvement in each, including increases in the estimated number of patients protected from complications and the cost savings realized by that protection.

A key tactic in the WHA’s campaign is the use of learning events, including coaching calls and webinars led by WHA staff, providing topic-specific content on what needs to improve and how to improve it. In 2013, about 100 monthly Web-based events took place, involving 1,800 improvement teams.

Moreover, Wisconsin’s utilization of inpatient stays is 5.7% better than the national average, as measured by inpatient days per Medicare beneficiary. The state’s rate of emergency-department visits is 3.7% lower than the national average. Wisconsin’s total annual Medicare payment per beneficiary is 9.3% lower than the national average.

Collegial Approach

Wisconsin’s experience is a testament to what collaboration among competing providers can achieve. “We had no trouble getting our member hospitals on board with Partners for Patients,” Court recalls. “They’re all committed to quality, and they understood that if they worked together and shared, they could improve their processes faster.”

Eric Borgerding, the WHA’s executive vice president, adds, “The health-care industry in Wisconsin has a long history of transparency—of exchanging information. We’ve been transmitting quality information via our CheckPoint site since 2004 and pricing information from our PricePoint website since 2005. The notion of reporting on quality or price issues has been around for a while, and it’s something we’ve always embraced. We take the Wayne Gretzky approach: We want members to go where the puck is going.”

“For each clinical topic, the WHA convenes webinars and coaching calls,” Court says. “We hold monthly learning sessions in which we teach best practices and improve our ability to share those practices. We consider ourselves facilitators and coordinators. We establish the learning events; we can provide coaching or make a connection with another hospital if one of our members is having problems.”

Court continues, “We review the list of issues every year, and we look for issues that may affect our meeting of pay-for-performance targets in the future. We always poll the hospitals about the topics they need help with, and we pay special attention to high-volume issues and safety issues.”

Getting Results

As the report shows, the WHA was able to measure the results of its various initiatives, and with very few exceptions, they have worked. In particular, the best practices that have been put in place to prevent infections have been remarkably successful.

Court explains that each infection-prevention initiative involves a bundle of best practices, all of which have to be performed correctly, each time. The initiative to reduce readmissions includes learning how to improve discharge instructions, such as telling patients exactly how to take their medications when they get home. “Our members have created partnerships with nursing homes, agencies on aging, and home-care agencies, so that the whole community is working on transitional care,” Court adds.

One issue that appears to be a growing hazard in the health-care industry is sepsis mortality. Bloodstream infections carry a mortality rate of about 40%. “Patient-family engagement is another issue that needs more discussion,” Court says. “We plan to provide more content in the coming year about engaging the family in patient-related decisions.”

Borgerding reiterates that he believes that Wisconsin is so far ahead of other states in reducing costs and readmissions (and improving quality of care) mainly because of WHA members’ long history of sharing information. “Quality improves when you report,” he insists. “People who pay for health care in this state should be able to see what they’re getting for their money.”

Court says, “We’re lucky, in Wisconsin, because our senior leaders set aggressive goals; they create direction. Our state’s health-care industry also has a high level of vertical integration. Between 60% and 70% of physicians in Wisconsin are employed by WHA members, and they’re held accountable, and offered incentives, in a different way from what accountability and incentives would look like if they were independent of the system.”

No Magic Bullet

Apparently, consistency and uniformity of procedure go a long way toward improving quality of treatment, keeping costs down, and reducing readmissions. The challenge, Court says, lies in ensuring that every patient receives every item in a given bundle of procedures—and has each item done right, every time.

“What’s changing,” Court explains, “is that hospitals and physicians are learning to do all four or five things for every patient. For example, to prevent a central-line infection, you must fully drape the patient; insert the line in a specific way, and only when necessary; take it out as soon as it’s not needed; cleanse the line in a specific way, whenever you change it; and always wear gloves. To prevent surgical-site infections, make sure the correct antibiotics are used prophylactically at the right time, that the skin is cleansed in a specific way, and so forth. There is no one magic bullet that will prevent infections. It’s a matter of doing all the procedures the right way, every single time.”

Court adds, “There’s not much dispute on what best practices are. Most of them have been researched and have been proven to work. If there’s any debate, it’s on specific implementation. If your data show that a certain method isn’t working, you try something different.” The WHA report includes a trend graph for each topic addressed, including calculations of the number of patients affected and associated cost savings.

Wisconsin is a largely rural state, with many small, remote communities, and when this program was begun, some observers were concerned about how difficult it might be to involve the smaller rural facilities. Court says that it turned out not to be an issue.

“Our smaller members are just involved as the biggest ones,” she reports. “They have committed leaders, and they don’t want to be perceived as providing an inferior level of care. Our small rural hospitals aren’t subject to the same penalties from Medicare and CMS for readmission, but they’re nevertheless committed to providing quality care—on principle, not so much because of federal penalties.”

Joseph Dobrian is a contributing writer for Health CXO